Hybrid Approach of a Complex Aneurysm of the Subclavian-Axillary-Brachial Axis: A Case Report.

BACKGROUND: Upper extremity arterial aneurysms are a rare, potentially limb-threatening disorder. Due to its rarity, the best treatment modality and outcomes are not entirely established; however, there is a consensus that open surgery is the first-line treatment. We present a complex case of an arterial aneurysm of the subclavian-axillary-brachial axis adequately treated using a hybrid surgical and endovascular treatment. CASE PRESENTATION: A 59-year-old man presented to the emergency department with acute ischemia of the right upper limb. An extensive thrombosed aneurysm of the subclavian-axillary-brachial axis was identified. The treatment was carried out in two stages. In the first phase, urgent limb revascularization was performed using the great saphenous vein to perform a subclavian-brachial artery bypass. Later, the aneurysm was excluded using a vascular plug and multiple coils. Successful treatment was achieved with no morbidity for the patient. CONCLUSIONS: Although the gold standard for treating upper limb aneurysms is open surgery, endovascular techniques can be a significant adjunct, reducing treatment morbidity and even mortality.

Emergency Repair of a Ruptured Para-Renal Abdominal Aortic Aneurysm in a Patient with a Functional Renal Graft: A Case Report and Review of the Literature.

INDRODUCTION: Rupture of and abdominal aortic aneurysm (AAA) in a kidney transplant patient is a rare and rarely reported event. Emergent treatment can be challenging and should achieve effective aortic repair while minimizing ischemic damage to the renal graft during aortic cross-clamping. Several renal protective measures have been proposed such as permanent or temporary shunts, renal cold perfusion and general hypothermia. CASE REPORT: We report the effective treatment of a para-renal AAA in a patient with a functional renal allograft. A temporary extra-corporeal axillofemoral shunt was constructed to maintain graft's perfusion during open surgical repair. EVAR was not an option due to a short aortic neck. The postoperative period was complicated by colon ischemia and aortic graft infection. At 3 years follow-up the patient was well and graft's function was unchanged. CONCLUSION: This case is a reminder that renal graft protection must be accounted for when AAA rupture occurs in kidney transplant patients. We reviewed the literature to find previously reported cases and how they were managed.

Surgical Thrombectomy, Fibrinolysis, Angioplasty and Stenting: A Combined Approach for Treatment of a May-Thurner Syndrome Presenting as Phlegmasia Cerulea Dolens.

INTRODUCTION: Phlegmasia cerulea dolens (PCD) is a rare complication of deep venous thrombosis (DVT). Massive ileo-femoral DVT is usually the cause and prompt treatment is mandatory as it represents a medical emergency. Reported amputation rates range from 12% to 25% and mortality ranges from 25% to 40%. Limb ischemia results from obstruction to arterial inflow secondary to extreme levels of venous hypertension. Primary treatment goal is restoration of venous outflow and can be achieved by endovascular or surgical techniques. After thrombus removal an underlying iliac vein stenosis may be present. May-Thurner syndrome, a condition where the left common iliac vein is compressed by the right iliac artery, is the most prevelant iliac stenotic lesion. METHODS: We report a case of a 57 years-old male, smoker, with no significant medical history, who presented to the emergency department with excruciating sudden left limb pain and swelling, with no trauma history, with a 2-hour onset. On physical examination he showed significant edema, purplish discoloration of the entire leg and absent dorsalis pedis artery pulse. RESULTS: Hipocoagulation with intravenous heparin was immediately initiated and emergent surgical venous thrombectomy was performed associated with direct intravenous fibrinolytic agent injection. Postprocedure phlebography showed a left common iliac vein lesion which was treated with angioplasty and venous stent placement. Pain, edema and coloration improved markedly after procedure without any complications. The patient was discharged home with anticoagulation treatment and compression stocking. CONCLUSION: Endovascular approaches such as catheter-directed thrombolysis (CDT) or pharmacomecanical thrombolysis (PMT) are becoming the treatment of choice to achieve venous outflow in DVT. In cases of PCD, when rapid restauration of venous outflow is mandatory, CDT has the disadvantage of having a long mean treatment time. This way, surgical thrombectomy still plays an important role in cases of PCD, especially if PMT is not available. In our case, the combined used of surgical thrombectomy with direct intravenous thrombolytic infusion provided effective treatment of PCD and uncovered an underlying left common iliac vein stenosis, which was successfully managed by angioplasty and stenting.

Dieta sem glúten e sem caseína no Transtorno do Espectro Autista / Dieta sin glúten y sin caseína en el Trastorno del Espectro Autista / Gluten-free and casein-free diet in the Autistic Spectrum Disorder

Introdução: O Transtorno do Espectro Autista (TEA) é uma síndrome na qual há uma degradação na interação social e na comunicação de seus portadores que apresentam atividades e interesses limitados, assim como alteração no comportamento. Sua prevalência continua crescendo, porém as pesquisas feitas até hoje não foram suficientes para desvendá-la completamente. A dieta sem glúten e sem caseína (SGSC) tem sido indicada como um tratamento específico para se obter melhoras na interação social, comunicação, comportamento e estereotipias. Pais e cuidadores têm relatado bons resultados após a inserção da dieta na alimentação do autista. Objetivo: Verificar o uso das dietas sem glúten e sem caseína como parte do tratamento terapêutico em portadores de Transtornos do Espectro Autista. Material e Método: Revisão bibliográfica com base em artigos originais publicados nos últimos dez anos. Resultados: Em nenhum artigo analisado encontrou-se alguma evidência conclusiva a respeito do uso da dieta SGSC. Embora utilizando diferentes metodologias a pequena quantidade de estudos dificulta a análise dos dados. Conclusão: Mesmo sem dados conclusivos, muitos pais e cuidadores inserem a dieta na alimentação do portador de TEA, sendo necessário que estes indivíduos tenham acompanhamento nutricional para que as restrições alimentares não causem desnutrição no paciente.

Introduction: The Autistic Spectrum Disorder (ASD) is a syndrome characterized by a breakdown in social interaction and in communication as well. The patients present restricted interests and activities, as well as behavioral changes. Despite the growing prevalence of the syndrome, the researches performed up to date were not able to completely unravel it. The gluten-free and casein-free diet (GFCF) has been indicated as a specific treatment in order to obtain improvements in social interaction, communication, behavior and stereotypes. Parents and caregivers have been reporting positive results after inclusion of this diet in autistic nutrition. Objective: to investigate the use of the gluten-free and casein-free diets as part of the therapeutic treatment in patients with ASD. Material and Method: Literature review based on original articles published in the last ten years. However, none of the analyzed articles displayed conclusive evidence regarding the use of the GFCF diet. Results: no article analyzed showed any conclusive evidence regarding the use of the GFCF diet. Although using different methods, the small amount of studies makes difficult the data analysis. Conclusion: Even without conclusive data, many parents and caregivers include this diet in the nutrition of patients with ASD, being necessary this way for these individuals a nutritional follow-up in order to avoid a malnutrition due to the food restrictions.

Introducción: El Trastorno del Espectro Autista (TEA) es un síndrome, en el cual hay una degradación en la interacción social y comunicación de sus portadores, presentando actividades e intereses limitados, así como alteración en el comportamiento. Su prevalencia continúa creciendo, sin embargo las investigaciones hechas hasta hoy no fueron suficientes para desvelar este síndrome completamente. La dieta sin glúten y sin caseína (SGSC) ha sido indicada como un tratamiento específico para obtenerse mejoras en la interacción social, comunicación, comportamiento y estereotipias. Padres y cuidadores han relatado buenos resultados después de la inserción de la dieta en la alimentación del autista. Objetivo: El objetivo de este trabajo es verificar el uso de las dietas sin glúten y sin caseína como parte del tratamiento terapéutico en portadores de Trastornos del Espectro Autista. Material y Método: Estudio realizado a través de repaso bibliográfico en artículos de estudios de casos en los últimos diez años. Resultados: En ningún artículo analizado se encontró alguna evidencia conclusiva acerca del uso de la dieta SGSC. Aunque el uso de diferentes métodos, la pequeña cantidad de estudios dificulta el análisis de los datos. Conclusión: Aún sin datos conclusivos, muchos padres y cuidadores insertan la dieta en la alimentación del portador de TEA, siendo necesario que estos individuos tengan acompañamiento nutricional para que las restricciones alimentarias no causen desnutrição en el paciente.

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.