Total Endovascular Aortic arch Replacement with Chimney/Sandwich Techniques.

Traditional open total zone 0 replacement of the aortic arch is one of the most complex, challenging, and demanding operative procedures in cardiovascular surgery, associated with significant morbidity (30-40%) and mortality (8-20%). Total endovascular zone 0 replacement of the aortic arch with chimney/sandwich techniques as described by Lobato and Camacho-Lobato is a feasible, less invasive, less demanding, and time-consuming option to hybrid and/or traditional open replacement of the aortic arch, particularly in the urgent/emergent settings. We are reporting a case of a 49-year-old patient with chronic type B aortic dissection complicated with descending thoracic aortic aneurysm and an unsuccessful zone 3 thoracic endovascular aortic repair, complicated with type Ia endoleak. He presented with an enlarging and symptomatic descending thoracic aortic aneurysm. An extended proximal (to the zone 0) and distal thoracic endovascular aortic repair was performed to ensure appropriate proximal and distal landing zones (C-TAG). Left subclavian artery endorevascularization was undertaken with periscope sandwich technique (Viabahn), while brachiocephalic trunk and left carotid artery endorevascularizations were carried on with the chimney graft technique (Viabahn). The procedure was uneventful and the one-month and one-year follow-up angio-computed tomography revealed no endoleaks, patency of all branches, and exclusion of the aneurysm.

[Hilar Renal Artery Aneurysm - Ex-vivo Reconstruction and Autotransplantation]. / Aneurisma Hilar da Artéria Renal - Reconstrução Ex-vivo e Autotransplante.

Renal artery aneurysm (RAA) is a rare entity with an estimated prevalence of 0.09%. The majority present asymptomatically and the diagnosis is made incidentally during an imaging test. Indications to treat have been subject of intense debate, nevertheless, there seems to be some consensus that RAA's greater than 2 cm in diameter, expanding, with thrombus or in pregnant women should be treated. Treatment options vary between surgical or endovascular approach. Hilar RAA presents a therapeutic challenge because of their anatomic location and may require extracorporeal arterial reconstruction and auto-transplantation. We describe a 71-year-old woman, with an incidentally diagnosed complex RAA, following the study for an abdominal discomfort. Computed tomographic angiography revealed a 13mm, saccular aneurysm located at the right renal hilum. We performed hand-assisted laparoscopic nephrectomy with ex-vivo repair of the RAA. The intervention and postoperative course were uneventful. At six months of follow up the patient keeps a well-functioning auto-transplant. RAA may be nowadays more frequently diagnosed due to the increasing use of imaging techniques. Hand- -assisted laparoscopic nephrectomy with ex-vivo repair and auto-transplantation is a challenging but feasible option for treating hilar RAA.

O aneurisma da artéria renal é uma entidade rara com uma prevalência estimada de 0.09% na população geral. A sua maioria apresenta-se de forma assintomática sendo o diagnóstico feito de forma incidental durante o estudo imagiológico por outra suspeita. As indicações para o seu tratamento têm vindo a ser alvo de grande debate na literatura contudo, parece haver algum consenso no sentido de tratar aqueles maiores que 2 cm de diâmetro, com crescimento ao longo do período de vigilância, na presença de trombo e em mulheres grávidas. As opções de tratamento variam entre cirurgia direta ou endovascular. Os aneurismas hilares representam um desafio em termos de abordagem cirúrgica pela sua localização requerendo em algumas circunstâncias reconstrução extracorporal e auto-transplante renal. Os autores descrevem um caso clínico de uma doente do sexo feminino, 71 anos de idade, a quem tinha sido incidentalmente diagnosticado um aneurisma hilar da artéria renal, no seguimento de estudo por desconforto abdominal. O estudo por angiotomografia computorizada revelou um aneurisma de 13mm, de conformação sacular, localizado a nível do hilo renal direito. Procedeu-se a nefrectomia via laparoscopia e reparação ex-vivo do aneurisma. O procedimento decorreu sem intercorrência bem como o seguimento efetuado à doente, mantendo-se o enxerto funcionante aos seis meses. O aneurisma da artéria renal é, hoje em dia, mais frequentemente diagnosticado no contexto do crescente uso de técnicas de exame imagiológicas. A nefrectomia via laparoscopia e reparação ex-vivo seguida de auto-transplante é um procedimento desafiante mas exequível com elevada taxa de sucesso no tratamento desta patologia.

Percutaneous Treatment Pseudo-Aneurism of the Hand in Hemophilic Patient.

INTRODUCTION: Pseudo aneurysms of the hand are infrequent lesions, usually associated with perforating trauma. The diagnosis is based on clinical suspicion and image confirmation of a pulsatile swelling. Various treatment modalities are currently described in the literature. METHODS: Presentation of a clinical case and discussion of the treatment strategy instituted. RESULTS: Clinical case: Man, 35 years old, with hemophilia A. History of perforating trauma of the palmar face of the right hand 3 weeks ago, having been sutured in the local hospital. Since then he notices a pulsatile swelling in the palm of the hand associated with paresthesias and decreased sensitivity in the index finger. A pseudo-aneurysm with 2x3cm was observed, partially thrombosed, and with probable origin in the palmar arch or in the common digital artery. He underwent angiography demonstrating the patency of the palmar arch but without perfusion of the pseudo-aneurysm, and the control dupplex scan showed complete thrombosis of the false aneurysm. After 2 months of follow-up, the dupplex scan was repeated and repermeabilization of the pseudo-aneurysm was verified. The patient was then treated with percutaneous Doppler-guided thrombin injection. Immediate thrombosis of the lesion was found, with no evidence of ischemic complications. He remained asymptomatic under clinical surveillance. CONCLUSION: For small pseudo-aneurysm conservative non- -interventional treatment with external compression may be effective. Conventional surgical treatment with simple ligation or arterial reconstruction may be indicated in larger pseudo-aneurysm. Recently, endovascular techniques such as coil embolization have also been described. Hemophilia A is a genetic disease of recessive hereditary transmission linked to the X chromosome, with deficiency of factor VIII of the coagulation cascade, which manifests with increased risk of hemorrhage. In this particular case, given the risk of hemorrhage, we chose minimally invasive percutaneous treatment, with clinical and imagological success and no complications. Percutaneous treatment by ecodoppler- guided injection of thrombin is an effective and safe treatment, particularly in pseudo-aneurysm associated with surgical risk factors.

Hilar Renal Artery Aneurysm - Ex-vivo Reconstruction and Autotransplantation.

INTRODUCTION: Renal artery aneurysm (RAA) is a rare clinical entity with an estimated prevalence of 0.15% to 0.1%in the general population. The majority of patients present asymptomatically and the diagnosis is made incidentally during a hypertension study test, and more rarely, fortuitously after backache. Indications to treat have been subject of intense debate, nevertheless there seems to be some consensus that RAAs greater than 2 cm in diameter, expanding RAA, with thrombus or in pregnant women should be treated. Treatment options vary between surgical or endovascular approach. The complex (hilar) RAA constitute a subset of RAA that present a therapeutic dilemma because of their anatomic location and may require extracorporeal arterial reconstruction and auto-transplantation. METHODS: We describe a 71-year-old woman with a personal history of hypertension for more than twenty years but normal renal function. Following the study for an abdominal discomfort a complex RAA was incidentally diagnosed. Computed tomographic angiography with three-dimensional reconstruction revealed a 13mm, saccular aneurysm located at the right renal hilum. RESULTS: We performed hand-assisted laparoscopic nephrectomy with ex vivo repair of the RAA. The aneurysm was resected and a polar renal artery was implanted over the resected area with a latero-terminal anastomosis. Complementarily, the renal vein was augmented with a spiral great saphenous vein graft and finally the kidney was implanted into the right iliac fossa. The intervention and postoperative course were uneventful and the patient submitted to ultrasound evaluation on the day after procedure. It revealed normal renal perfusion with normal flow indices. In the last follow-up realized, two months after surgery the patient was alive with a well-functioning auto-transplant. CONCLUSION: RAA may be nowadays more frequently diagnosed due to the increasing use of imaging techniques. While renal artery trunk aneurysms are most often treated using an endovascular procedure it is not suitable for renal artery branch aneurysms. Hand-assisted laparoscopic nephrectomy with ex vivo repair and auto-transplantation is a challenging but feasible option for treating hilum RAA.

Evaluation of different end-of-life management alternatives for used natural cork stoppers through life cycle assessment.

An important aspect of sustainable development is the implementation of effective and sustainable waste management strategies. The present study focuses on a Life Cycle Assessment (LCA) approach to different waste management strategies for natural cork stoppers, namely incineration at a municipal solid waste incinerator, landfilling in a sanitary landfill, and recycling. In the literature, there are no LCA studies analyzing in detail the end-of-life stage of natural cork stoppers as well as other cork products. In addition, cork is usually treated as wood at the end-of-life stage. Thus, the outcome of this study can provide an important insight into this matter. The results showed that different management alternatives, namely incineration and recycling, could be chosen depending on the impact category considered. The former alternative presented the best environmental results in the impact categories of climate change, ozone depletion and acidification, while the latter for photochemical ozone formation and mineral and fossil resource depletion. The landfilling alternative did not present the best environmental performance in any of the impact categories. However, when the biogenic carbon dioxide emission was assessed for the climate change category, the landfilling alternative was found to be the most effective since most of the biogenic carbon would be permanently stored in the cork products and not emitted into the atmosphere. A sensitivity analysis was performed and the results showed that there are various parameters that can significantly influence the results (e.g., carbon content in cork and decay rate of cork in the landfill). Thus, LCA studies should include a detailed description concerning their assumptions when the end-of-life stage is included in the boundaries since they can influence the results, and furthermore, to facilitate the comparison of different end-of-life scenarios. The present study and the obtained results could be useful for the decision-making process concerning public solid waste policies and industrial strategies.

Hybrid approach in a case of persistent sciatic artery aneurysm.

Persistent sciatic artery is a rare congenital vascular malformation with a reported incidence between 0.03% and 0.06%. An 82-yr-old woman presented to our institution with right acute lower limb ischemia compatible with a cardioembolic etiology. A popliteal embolectomy was performed to the patient, and at the end of the procedure, she had bilateral lower limb distal pulses. Six months after the procedure, the patient complained with right lower limb rest pain, an angiography and a computed tomography angiography were performed showing a sciatic artery aneurysm with 4.6 cm of diameter and patency of the sciatic artery to the popliteal artery. A femoropopliteal bypass and retrograde coil embolization of the sciatic aneurysm through the popliteal artery and distal sciatic artery ligation were performed. The patient was discharged 7 days after the procedure, and she remains asymptomatic. Our patient had a complete type of persistent sciatic artery with aneurysmatic degeneration. Correction of the distal ischemia with aneurysm exclusion was achieved with a simple noncomplicated hybrid procedure.

Iatrogenic arteriovenous fistula following endovenous laser therapy of the short saphenous vein.

Short saphenous vein incompetence is present in up to 20% of patients with varicose veins. Studies looking at the success and complication rates associated with endovenous laser ablation of the short saphenous vein included only a small number of patients. The authors report the case of a 51-year-old woman presenting with a painful right leg edema. She had a history of previous endovenous laser ablation of the right and left great saphenous veins and right short saphenous vein. Duplex scan was performed and showed an arteriovenous fistula between branches of the popliteal artery and vein. Surgical ligation of the fistula was performed. At 8-month follow-up, the patient remains asymptomatic.