[Endovascular management of an infectious and ruptured abdominal aortic aneurysm. Clinical report]. / Tratamento endovascular de um aneurisma infeccioso da aorta abdominal em rotura - Caso Clínico.

Infectious aneurysms are about 1-3% of all aneurysms of the infrarenal aorta. Its treatment is challenging and the best strategy is far from consensual. The authors report a case of a HIV + patient with multiple other co-morbidities, which was seen in the emergency department with fever and left back pain. These symptoms would prove to be in relation to a ruptured infectious aneurysm of the abdominal aorta. Facing this situation it was decided to select an endovascular technique with implantation of an aorto uni - iliac stent graft with a right-left femoro-femoral cross-over using a 8 mm PTFE graft and exclusion of the left common iliac . The patient didn't have any complication from the situation or the procedure, but died 18 months postoperatively because of a pneumonia caused by Pneumocystis jiroveci. Although it is not the ideal solution for the treatment of infectious elective aneurysms, we believe that endovascular treatment seems to be a viable option and should be taken into account in a subgroup of patients that for their co-morbidities are not good candidates for conventional surgery and for those in rupture, either as a bridge or as a final solution.

[Complications of vascular access for hemodialysis - limits, imagination and commitment]. / Complicações dos acessos vasculares para hemodiálise - limites, imaginação e empenho.

Terminal chronic kidney disease courses with high mortality and is a serious public health problem on a global scale. In Portugal, it involves about 14,000 patients of whom 5,000 are transplanted. The remaining require permanent renal replacement techniques. Every year, there are 2,200 new cases and the mortality rate is around 20%. One of the most important determinants for the survival of hemodialysis patients is the quality of vascular access. The role of the vascular surgeon is to planify and to do the best access possible, monitoring and fight for its patency and thereby improve not only the quality of life but also to combat mortality associated with complications of vascular access - first cause of hospital admission of these patients. The authors report 10 clinical cases in which the limits of the hemodialysis surgery were tested and where it was necessary commitment and imagination to prevent the vascular access loss. The management of some complications is a challenge for the vascular surgeon and currently it is necessary to find hybrid/complementary solutions. Examples of some complications and challenges are steal syndromes, venous hypertension, vascular access in unusual places and 'total' failure of vascular access. Focusing on maintaining vascular access working improves the quality of dialysis, quality of life for patients, saves vascular capital for future access and in extreme cases, saves lifes.

[Some reflections on the Klippel Trenaunay syndrome: A single entity or an association of vascular malformations]. / Algumas considerações sobre o syndrome de klippel trenaunay: uma entidade única ou um conjunto de malformações vasculares?

The author started in the year 2000, in the St Marta Hospital, a consultation for congenital vascular malformations, that was extrapolated to the Pulido Valente Hospital - CHLN where he continues to see multiple patients with this type of pathology, mainly located to the extremities.The Klippel Trenaunay syndrome, which was described as a set of anomalies constituted by the presence of a cutaneous angiomatous malformation ( port wine stain ), varicose veins and gigantism of the limbs, is undoubtedly the most common malformations that he is asked to treat. So he thought that it would be interesting to undertake an actual review of this pathology.After analyzing the various components in question he concludes that the condition is undoubtedly a set of malformations ranging from a cutaneous component, to the venous and lymphatic malformations and clear the osseous component, that causes the bone dysmorphic appearance, and that is essential a multidisciplinary approach to achieve a final satisfactory therapeutic result.

[Cubital artery aneurysm and hypothenar hammer syndrome. Report of an unusual case]. / Aneurisma da artéria cubital e síndrome do martelo hipotenar. Considerações sobre um caso clínico pouco frequente.

Hypothenar hammer syndrome (HHS) is a rare condition and is a term used to described an aneurysm or thrombosis of the ulnar artery. It is considered an occupational or recreational injury and usually results of repetitive trauma to the hypothenar region, where th unique anatomy after the artery leaves the Guyon canal, allows the arterial injury. Clinical manifestations are more often unilateral, involving the dominant hand. However, some authors report the existence of a previous arteriopathy, predisposing to the injury, after repetitive palmar trauma.The authors report the clinical case of a 60 year-old woman, with an ulnar aneurysm in the non dominant hand, without evident existence of repetitive trauma. The pathological examination of the artery revealed muscular hyperplasia, without the characteristics of muscular fibrodysplasia. The authors believe that this case, once again, demonstrates the existence of an autonomous and "previous" arteriopathy associated to the traumatic lesion.

[Salmonella typhimurium aortitis]. / Aortotite causada por salmonella tiphymurium.

Salmonella tiphymurium infection frequently causes gastroenteritis but some cases have a predilection for damaged blood vessels, especially those affected by atherosclerosis. The abdominal aorta is the most frequent location. Salmonella aortitis with mycotic aneurysm formation is a rare but serious condition, due to the high risk of rupture. We report the clinical case of a 61 year old man with a history of diabetes and hypertension, who was previously admitted with Salmonella gastroenteritis for which he had been treated with proper antibiotics. He was readmitted with fever, nausea and low back pain. Salmonella thyphimurium was isolated in blood cultures. The investigation revealed a pseudoaneurysm formation on the abdominal aorta. He was submitted to surgical vascular grafting with aneurysm resection and antibiotic therapy before and after surgery, with excellent clinical outcome. Bacteremia due to Salmonella Typhymurium must always raise the suspicion of focalization, especially a vascular infection. Particular attention should be given to predisposing factors, such as pre-existent atherosclerosis and age. The advised treatment of mycotic aneurysm due to a Salmonella agent must be a combined medical and surgical therapy.

[Valvular transposition in patients with ulcers of the lower limbs following post thrombotic syndromes]. / A transposição valvular nos doentes com úlceras dos membros inferiores consequentes a síndromes pós-trombóticos.

Venous ulcers in patients with post thrombotic syndromes are complex situations with multiple therapeutic options. They are responsible for high morbidity rates, conservative treatment is very slow and recurrences are very common. Deep venous reconstructive surgery is an alternative, but it should be based on the morphologic and functional aspects of the venous system and only adopted after a very careful study, including venography. The authors describe a morphological "pattern", found in some of these patients and related to the competence of the saphenous femoral junction, rendering possible to perform a valvular transposition. Seven patients with post thrombotic ulcers who have been treated during the last 6 years in which the pattern already described was detect, underwent a transposition of the superficial femoral vein, to the great saphenous vein and when necessary complemented with skyn grafts. Before the operation all patients had ulcers with more than 3 cm in size (3.2-5.4 cm) and with more than 4 months duration (4-16 months). All ulcers healed in the postoperative period (mean time 28 days). All patients have been reevaluated in 2003 and it was diagnosed the thrombosis of two procedures, one of them with the recurrence of the ulcer who healed with conservative treatment. The authors consider this method as a very easy technique to perform, although rarely used, and a valid alternative in a highly selected group of patients.

[Post-traumatic pseudo aneurysm of the infrarenal aorta. A clinical report]. / Falso aneurisma traumático da aorta infrarenal. A propósito de um caso clínico.

Abdominal aortic pseudoaneurysms are rare, particularly when they are related to blunt abdominal trauma. The authors report the clinical case of a 65 years old man with an abdominal aortic pseudoaneurysm related to a blunt abdominal trauma, that occurred three years ago. The patient complained of a diffuse abdominal pain, increased while walking. The diagnosis was confirmed by angiography and by angio-CT. An aortic resection and interposition graft was performed, according to the age of the patient and the low operative risk. A discussion on the therapeutic option was made, followed by a revision of the literature on the subject, and the authors conclude by emphasizing the need of a detection of this type of pathology, particularly in patients who had suffered in the past violent trauma.

[Churg-Strauss syndrome, femoral venous aneurysms and pulmonary thromboembolism]. / Síndrome de Churg-Strauss, aneurismas femorais venosos e tromboembolismo pulmonar.

OBJECTIVE: Venous aneurysms of the lower limbs are rare. When they involve the deep venous system, they can be associated with deep venous thrombosis and pulmonary embolism. The authors report the case of a 63-year-old women evaluated by duplex imaging and venography, in the context of a pulmonary embolism, and detected bilateral large aneurysms of the femoral veins (5 cm in the right femoral vein and 4 cm in the left femoral vein). The aneurysms were located at the bifurcation of the common femoral vein with the superficial and profound veins. METHOD: The right aneurysm was partially thrombosed. The patient was asymptomatic in the lower-limb extremities. After a period of anticoagulation, the authors proceeded to surgically excise the right aneurysm and replaced the venous system using a polytetrafluoroethylene (PTFE) graft with the construction of an a-v fistula. RESULT: The patient had no complications in the postoperative period and her 8-month follow-up examination revealed no symptoms, not even leg edema. The duplex scan showed patency of the graft. She continued with oral anticoagulation. The histologic examination revealed an eosinophilic inflammatory reaction of the vein wall, compatible with the diagnosis of Churg-Strauss syndrome. CONCLUSION: The authors conclude that they have probably described the first case in the international literature of a venous aneurysm with a Churg-Strauss syndrome and pulmonary embolism.