Objective: To analyze the experience in the treatment of bilateral complex arterial aneurysms of the renal arteryIntroduction: Renal artery aneurysms are a rare clinical entity and the epidemiology, pathophysiology and best treatment are not clearly defined in the literature.Material and Methods: Retrospective analysis of the database of patients with the diagnosis of renal artery aneurysms. A total of 3 patients with bilateral aneurysms were surgically treated and a descriptive analysis was applied on a case-by-case basis. ResultsClinical case 1: A 46-year-old female patient with arterial hypertension with incidental diagnosis of two saccular aneurysms of the right renal artery and two saccular aneurysms of the left renal artery. A left nephrectomy was performed laparoscopically and an aneurysmectomy and angioplasty with internal saphenous vein and kidney implant were performed in the left iliac fossa. Four months later, the right kidney was treated with laparoscopic nephrectomy, aneurysmorrhaphy associated with aneurysmectomy and bypass with internal saphenous vein, renal vein extension with internal saphenous vein spiral prosthesis and implantation of the kidney in the right iliac fossa.Case report 2: Female patient, 38 years old, arterial hypertension with incidental diagnosis of two saccular aneurysms of the right and left renal arteries. A left nephrectomy was performed laparoscopically and the aneurysms were excluded with Yasergil titanium clips associated with aneurismorrhaphy and left iliac fossa implant. Four months later, a right laparoscopic nephrectomy was performed and aneurysms were treated with aneurysmorrhaphy and renal vein extension, with spiral vein prosthesis of the internal saphenous vein, and implantation in the right iliac fossa.Clinical case 3: A 33-year-old male patient with the incidental diagnosis of two fusiform aneurysms of the right renal artery and two saccular aneurysms of the left renal artery. A right nephrectomy was performed laparoscopically, and the renal polar artery was ligated because of the impossibility of reconstruction and the kidney was implanted in the right iliac fossa. Seventeen months later, a left nephrectomy was performed laparoscopically and aneurysmectomy was performed in association with two renal bypasses with internal saphenous vein and implantation of the kidney in the left iliac fossa.Discussion and conclusion: The treatment of bilateral aneurysms is rare and, in 2014, the first case of autotransplant treatment was published. There are, however, no randomized trials comparing in situ, ex vivo and endovascular surgery. At our center, the treatment of complex renal artery aneurysms, which we defined as those requiring greater than 45 minutes of renal artery clamping time or located in artery areas not accessible to in situ reconstruction, is performed through ex-vivo surgery and autotransplantation in the iliac fossa. This therapy represents an excellent option with zero morbidity and mortality. Experience in renal transplantation and vascular surgery is a key requirement for successful treatment.  

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

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

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

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

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

INTRODUCTION: Due to their relative rarity, the natural history of iliac artery aneurysms and treatment outcomes are poorly understood. However, IAA treatment has evolved, and nowadays, there are a variety of open surgery, endovascular therapy, and hybrid options. This study aimed to compare the outcomes of endovascular treatment versus open surgery for patients with iliac artery aneurysms. METHODS: A systematic review was performed according to the PRISMA statement. An online search was conducted using the Medline database from January 2014 to January 31st, 2023. Only original articles in English or Portuguese, reporting on a minimum of 5 cases, were considered. Studies were included if reporting at least one of the following outcomes: peri-operative complications, length of stay (LS), and 30-day mortality. The software Review Manager 5.4 was used for data analysis. RESULTS: The database search identified 418 articles, of which 413 records were excluded by screening by title/ abstract, and five were read in full and subsequently included.A total of 1837 patients were included. Open surgery was performed in 29.02% (442/1523) and endovascular in 70.58% (1075/1523). More than half of endovascular cases included internal iliac artery preservation techniques (iliac branch design grafts). Patients undergoing endovascular treatment were significantly older (mean difference [MD]: 5.49, 95% confidence interval [CI]: 2.34 to 8.65) and more likely to have congestive heart failure (odd ratio [OR]: 3.74, 95% CI: 1.24-11.27). On the other hand, patients undergoing open surgery were more often smokers (OR: 0.59, 95% CI: 0.42-0.82). The primary outcome - 30-day mortality - was significantly higher for open surgery (OR 0.34, 95% CI 0.19-0.61). Considering other peri-operative outcomes, patients undergoing open surgery presented with longer length of hospital stay (MD: -4.68, 95% CI: -6.43 to -2.92), higher risk of surgical wound infection (OR: 0.31, 95% CI: 0.10- 0.94), renal failure (OR: 0.37, 95% CI: 0.18-0.75) and respiratory infection (OR: 0.19, 95% CI: 0.11-0.33). No significant differences regarding buttock claudication and leg and bowel ischemia were found. The 30-day reintervention rates weren ́t significantly different for open and endovascular surgery (OR 0.83, 95% CI 0.33-2.1). CONCLUSION: Endovascular treatment of iliac artery aneurysms can reduce 30-day mortality, peri-operative complications and length of hospitalization. No differences were identified regarding 30-day reintervention rates. Consequently, endovascular treatment has gained preference over open surgery as the initial approach for patients with suitable anatomy. No other meta-analysis in the literature compares the results of open surgery and endovascular treatment, particularly the results of new endovascular techniques (iliac branch design grafts). Comparing long-term reintervention rates will be essential in the future.

INTRODUCTION: Splenic artery aneurysms (SAA) are the most frequent (50 to 75%) abdominal visceral arterial aneurysms. In autopsy studies, the overall incidence is 0.01%, increasing to 10.4% with age. Due to their rarity, there is a lack of data, so we aimed to perform a systematic review of available SAA data. METHODS: A systematic review was performed according to the PRISMA guidelines. A literature search was performed using the Medline database from January 2019 to January 2024. Only full-text articles were considered, including patients with true SAA treated by endovascular (ET) and/or open surgical (OS) means. Only articles published in English or Portuguese were considered. The investigated outcomes were postoperative complications, reinterventions, and mortality.. RESULTS: Of the 289 articles identified during the initial literature search, 87 were included in qualitative synthesis. One thousand sixty-one patients were identified with 1085 reported SAAs. The mean age was 51.62 years +/- 14.57, with older patients in the OS group (OS 54.49 years +/-15.95 vs. ET 51.92 years +/-12.83) and 39.8% (range 29.5-50.0) were male (OS 34.5% [16.2-52.8] / ET 41.7% [27.0-56.3]). A total of 12.6% (0.3-24.9%) were detected during pregnancy, with a higher frequency of pregnancy also in the OS group (OS 29.5% [0.0-9.3])/ ET 7.2% [0-14.6%]). The mean diameter was 3.18cm +/- 2.07 (OS 4.95cm +/- 3.74 vs. ET 3.10cm +/- 1.92). The frequency of rupture was 2.8% (0.0-8.9%) and much higher in the OS group (OS 37.5% [0-100%] vs. ET 6.5% [0.0-23.4]). The types of intervention reported were ET (744 patients) and OS (317 patients: 281 conventional open reconstruction, 25 laparoscopic, and 11 robotic). Postoperative complication rates were 12.4% (2.1-22.6) in the ET group and 9.1% (5.6-12.6) in the OS. The reintervention rate at 30 days was 5.2% (1.6-10.4) in the ET group. Reintervention after OS was 4.7% (2.2-7.2). Overall, there were three perioperative deaths, all in the OS group (mortality: 23.0 [95% CI 0.0-96.3]. CONCLUSION: SAAs rupture is associated with high mortality, so timely diagnosis and management are essential to attain a satisfactory outcome. A detailed and individualized analysis of each case and a sufficient understanding of the anatomy and hemodynamics of a particular aneurysm should guide the therapeutic decision. OS has good results in treating SAA with lower morbidity and reintervention than ET. However, ET should be a viable alternative in high-risk patients with favorable anatomy.

BACKGROUND: Although the traditional standard of care for aortic arch aneurysms is open surgical arch replacement, this approach usually requires sternotomy, cardiopulmonary bypass and hypothermic arrest. Even among the subset of patients fit for open surgery, it is associated with a pooled mortality and stroke rate of around 5%. Nowadays, a multidisciplinary team of vascular and cardiac surgeons is mandatory to determine the best, individualised treatment for each patient. CASE REPORT: A 70-year-old male was incidentally diagnosed with an asymptomatic saccular aortic arch aneurysm. After a discussion with vascular and cardiac teams, a total endovascular arch repair was decided. Percutaneous access was obtained to the right femoral and axillary arteries, the left brachial artery, and the left femoral vein. Only the left carotid artery was surgically exposed. A Cook custom-made three-inner-branched stent graft was deployed under temporary inferior vena cava occlusion. Two anterograde branches for the innominate trunk (bridged with a 12 mm-diameter iliac limb) and the left carotid artery (bridged with a 6 mm Bentley Begraft balloon-expandable covered stent), and a retrograde branch with a preloaded catheter for the left subclavian artery (bridged with a 10 mm Gore Viabahn self-expandable covered stent, relined with a 10 mm Bentley Begraft due to a kink) were implanted. The procedure was successfully completed, and the patient was discharged after three days. Computed tomography angiography at three months demonstrated aneurysm exclusion, patency of the three supra-aortic branches and absence of cerebral ischemic lesions. CONCLUSION: In the elective setting, a triple-branch custom-made device enables total endovascular arch repair without the need for surgical revascularisation, thereby reducing invasiveness and morbidity, even in non-high-risk patients with suitable anatomy. A third branch also allows upper-extremity access for future visceral branch endovascular interventions.