Abstract Introduction: Vascular Surgery is a demanding specialty with vast technological and research advances in the last decades. This has led to an increasing complexity of providing adequate training programs for the modern Vascular Surgeon. Our aim was to understand the current satisfaction rates and perceived limitations of the Vascular Surgery residency program in Portugal by performing an online survey to residents. Methods: A survey study was conducted between April and June 2021 targeting Angiology and Vascular Surgery Residents in Portugal. Residents were contacted by e-mail from the National Portuguese Society of Angiology and Vascular Surgery to answer the survey. The survey was anonymized, and all residents from the 1st to 6th year were invited to participate. The survey was carried out using the Google® Forms platform and using Portuguese language. Questions were developed with two main objectives, the first being to analyze the satisfaction rates with the current residency program and the second to understand current limitations and possible areas of improvement. Results: Overall, 33 (65%) out of 51 invited residents participated in the survey, with equally distributions regarding the year of residency. Nineteen residents were male (57.6%). Most residents considered that the current one-year General Surgery rotation should be reduced and replaced by other specialties such as Radiology. Main surgical limitations were found with open aortic surgery. However, when compared to other European countries, residents considered that the main current limitation was scientific/academic training. Most residents were satisfied with their residency and felt professional fulfillment, however, most also reported having an unhealthy work-life balance and lack of time for academic and scientific research. When comparing the survey answers between younger and older residents, older residents reported more often having considered quitting and having experienced bullying or harassment. Conclusion: The findings from this study provide insight into the perceptions of the trainees regarding current training limitations and satisfaction rates with the residency program and may provide a base for improvement and development strategies in the residency programs in Portugal.

Abstract Introduction: Vascular Surgery is a demanding specialty with vast technological and research advances in the last decades. This has led to an increasing complexity of providing adequate training programs for the modern Vascular Surgeon. Our aim was to understand the current satisfaction rates and perceived limitations of the Vascular Surgery residency program in Portugal by performing an online survey to residents. Methods: A survey study was conducted between April and June 2021 targeting Angiology and Vascular Surgery Residents in Portugal. Residents were contacted by e-mail from the National Portuguese Society of Angiology and Vascular Surgery to answer the survey. The survey was anonymized, and all residents from the 1st to 6th year were invited to participate. The survey was carried out using the Google® Forms platform and using Portuguese language. Questions were developed with two main objectives, the first being to analyze the satisfaction rates with the current residency program and the second to understand current limitations and possible areas of improvement. Results: Overall, 33 (65%) out of 51 invited residents participated in the survey, with equally distributions regarding the year of residency. Nineteen residents were male (57.6%). Most residents considered that the current one-year General Surgery rotation should be reduced and replaced by other specialties such as Radiology. Main surgical limitations were found with open aortic surgery. However, when compared to other European countries, residents considered that the main current limitation was scientific/academic training. Most residents were satisfied with their residency and felt professional fulfillment, however, most also reported having an unhealthy work-life balance and lack of time for academic and scientific research. When comparing the survey answers between younger and older residents, older residents reported more often having considered quitting and having experienced bullying or harassment. Conclusion: The findings from this study provide insight into the perceptions of the trainees regarding current training limitations and satisfaction rates with the residency program and may provide a base for improvement and development strategies in the residency programs in Portugal.

Abstract Introduction: Fenestrated/branched EVAR (f/bEVAR) are associated with lower peri-operative major complications, when compared to open repair in complex aortic pathologies. However, f/bEVAR is limited by the waiting time for customized graft production and has specific anatomic limitations. Alternatively, adapting outside instructions-for-use, readily available off-the-shelf devices has been used with variable success. Among these options is the Octopus technique, which consists of parallel stent grafts originating inside a larger external stent graft. Despite being an off-label combination of devices, it can play a role when f/bEVAR is unavailable or inapplicable. Methods: Single center retrospective study, including all consecutive patients treated with the Octopus technique. Baseline characteristics, peri-procedural and follow-up data was obtained. Primary endpoint is clinical success. Secondary endpoints are complications and secondary interventions in follow-up. Results: Between 2015 and February 2022, six patients with a mean of 74±9 years were identified. Treatment indications included three type 1A endoleaks and 3 thoracoabdominal aortic aneurysms (TAAA) without prior intervention, one of which was mycotic. Four procedures were elective and the remaining two emergent. In the elective cases, the Octopus technique was chosen due to anatomical constraints and because waiting time for customization was considered excessive. Excluder and Incraft endografts were used in 5 and 1 cases, respectively. Thirteen visceral branches were revascularized (6 superior mesenteric, 4 renal and 3 celiac arteries). Gutter endoleaks were observed in 2 patients. Mean blood loss, surgery and hospitalization duration was 483 (300) mL, 288 (73) minutes and 26 (19.5) days. One perioperative death occurred, in a patient treated in the context of post-EVAR rupture due to type 1A endoleak. The most frequent postoperative complications were temporary acute renal failure (2/6), paraplegia (2/6) of which one was completely resolved, and non-graft related infection (2/6). One early reintervention, consisting of branch relining due to kinking and gutter embolization was necessary. On follow-up, there were no new endoleaks or endoleak-related interventions. Four patients died within two years, one with an aneurysm-related complication (spondylodiscitis in the context of a mycotic TAAA). The remaining deaths were not aneurysm related. Conclusion: The Octopus technique may offer a valuable off-the-shelf solution for complex aortic diseases, particularly due to anatomical constraints or in the emergent setting. Despite a high technical success rate, there is significant early morbidity and high mid-term mortality. In our series, durability was reasonable for this challenging group of patients, and our outcomes are in accordance with other reports.

Abstract The objective of this work was to evaluate the effect of salinity on Na+ and K+ distribution and on proline content in Urochloa brizantha and Urochloa decumbens grass cultivars. Plants were grown in nutrient solution and subjected to salt stress for nine days. Shoot and root lengths and proline, total chlorophyll, K+, and Na+ contents were determined. Salt stress reduced the shoot length of cultivar Marandu but not of Xaraés and Basilisk. Total chlorophyll content was not affected by salinity in U. brizantha cultivars, but increased in cultivar Basilisk of U. decumbens. Salt-induced proline accumulation was observed in all cultivars, with a higher increase in Marandu. The K+ content in leaf blades increased in the Marandu and Basilisk cultivars under salinity conditions. 'Basilisk' showed Na+ exclusion in shoot tissues, whereas 'Marandu' and 'Piatã', followed by 'Xaraés', exhibited a higher Na+ in leaf blades. The pattern of ion distribution among cultivars was attributed mainly to differences in the ability to control the ion transport from root to shoot, since the rates of ion uptake were similarly affected by salinity. Tolerance to salt stress in grasses of the Urochloa genus is associated to Na+ exclusion and not to proline accumulation in shoot tissues.

Resumo O objetivo deste trabalho foi avaliar o efeito da salinidade na distribuição de K+ e Na+ e no conteúdo de prolina em cultivares dos capins de Urochloa brizantha e Urochloa decumbens. As plantas foram cultivadas em solução nutritiva e expostas a estresse salino durante nove dias. Foram determinados os comprimentos da parte aérea e das raízes e os conteúdos de prolina, clorofila total, K+ e Na+. O estresse salino reduziu o comprimento da par te aérea da cultivar Marandu, mas não de Xaraés e Basilisk. O conteúdo total de clorofila não foi afetado nas cultivares de U. brizantha, mas aumentou na cultivar Basilisk de U. decumbens. Observou-se acúmulo de prolina em todas as cultivares sob estresse salino, com maior aumento em Marandu. O conteúdo de K+ nos limbos foliares aumentou nas cultivares Marandu e na Basilisk, em condições de estresse. 'Basilisk' apresentou exclusão de Na+ nos tecidos aéreos, enquanto 'Marandu' e 'Piatã', seguidas por 'Xaraés', apresentaram maior acúmulo de Na+ nos limbos foliares. O padrão de distribuição de íons entre as cultivares foi atribuído, principalmente, a diferenças na habilidade para controlar seu transporte da raiz aos tecidos da parte aérea, já que as taxas de absorção foram similarmente afetadas pela salinidade. A tolerância à salinidade em gramíneas do gênero Urochloa está associada à exclusão de Na+ e não ao acúmulo de prolina na parte aérea da planta.

Abstract Introduction: Renal cell carcinoma (RCC) frequently progress to involve the inferior vena cava (IVC) and even the right atrium (RA). Nephrectomy and eradication of the tumour thrombus, can extend survival and prevent symptoms of venous congestion. The authors evaluated the institutional experience of a tertiary center in the surgical management of RCC patients with tumour thrombi invading the IVC. Methods: Retrospective analysis of a single-center consecutive serie of patients with RCC and IVC tumor thrombi treated with surgery in our department between 2012 and 2021 was carried out. Demographic data, diagnostic and procedural characteristics, clinical outcomes and survival analysis were examined. Results: Of the included 18 patients, 33% (n=6) had smoking history, 78% (n=14) hypertension, 33% (n=6) diabetes and dyslipidaemia. Mean tumour size was 8.78±2.47cm (3-12cm), and 67% (n=12) of the cases were renal clear cell adenocarcinoma. On the basis of the Neves classification for IVC thrombus extension, 39% (n=7) of the patients had level I; 28% (n=5) level II; 17% (n=3) level III and 17% (n=3) level IV. The majority underwent radical nephrectomy, with cavotomy and vena cava thrombus removal followed by lateral venorrhaphy of the vena cava (89%,n=16). In one patient an infra-renal IVC ligation was performed and, in another patient, an IVC interposition with PTFE and a protesic-renal bypass were performed. In level IV, combined open sternotomy and cardiac bypass for RA thrombus control were necessary. Mean total operative time was 3h4min±1h19min and median intraoperative blood loss was 600ml requiring a median blood cells transfusion of 3.5units (0,16) during the hospital stay. Median ICU days was 2 days (0,14) and median hospital stay was 8 days (4,61). The mean preoperative serum creatinine was 1.23+0.38 mg/dL. After surgery, there was a mean decrease of serum creatinine of 0.001 mg/dL (p=.991) (paired T test), confirming the absence of renal impairment. Only one patient required reintervention in the post-operative course for splenectomy. Post-operative complications included one case of pulmonary embolism, pneumonia, acute coronary syndrome and two cases of temporary acute renal lesion. There was no 30-day mortality. Five patients underwent adjuvant chemotherapy. Median follow-up time was 19.5 months (6-46.2 months). The four-year overall survival rate was of 52.4% (figure 1). Conclusion: For advanced RCC with tumour thrombus extension into the IVC, despite the expected poor prognosis, nephrectomy and eradication of the entire tumour thrombus, has low morbidity and can prolong patient survival, in line with the presented results.

Abstract Introduction: Delayed type Ia endoleaks are often associated with proximal extension of the aneurysmal degeneration to the juxtarenal aortic segment. Endovascular treatment of type Ia endoleaks secondary to aortic neck dilatation can raise many technical challenges related to the previous implanted stent graft. Case report: The authors present a clinical case of an 84 year-old man, with a past medical history of atrial fibrillation, acute ischemic stroke, hypertension and dyslipidemia, that initially underwent an EVAR for a 5.5.cm infrarenal AAA with a TREO Bolton® endograft. After 3 years of follow-up, the CTA scan showed a delayed type Ia endoleak secondary to aortic neck dilatation with significant growth of the aneurysmatic sac. An endovascular proximal extension was planned, using a Zenith Fenestrated (ZFEN) platform (Cook Medical, Bloomington, Ind) but the short distance to the previous EVAR bifurcation did not allow the implantation of a standard 94cm CE fenestrated stent graft. To overcome this challenge, on-table modification of the fenestrated stent graft was performed by cutting the distal aortic stent. The stent graft was partially deployed on-table, the distal stent was cut with thermocautery, and the device was re-sheathed. The fenestrated cuff was then implanted in the standard fashion with target vessel catheterization and stenting. Two aortic covered stents (Aortic Begraft Bentley® 18mm) were implanted inside each iliac limb of the previous EVAR and sealed proximally in a parallel graft configuration on the fenestrated cuff. The final completion angiogram demonstrated perfusion of the visceral arteries, resolution of the Ia endoleak and without further endoleaks, as well as perfusion of both hypogastric arteries. At two months of follow up, the patient remains asymptomatic and the CTA scan showed resolution of the type Ia endoleak but the presence of a late type II endoleak. Discussion: Delayed type Ia endoleaks associated with proximal extension of the aneurysmal degeneration to the juxtarenal aortic segment, can raise some technical difficulties related to the previous implanted stent graft. Careful evaluation of patient anatomy and previous endografts should be done in planning for these procedures. On table physician modification of stent grafts is a valid solution to overcome challenging cases limitations. Further long-term follow-up is needed.

Resumo Um dos maiores dilemas diante de uma lâmina de citopatologia é o diagnóstico diferencial de lesões foliculares da tiroide agrupadas como lesões de padrão folicular e que incluem; bócio, adenoma (AF) e carcinoma foliculares (CF), carcinoma papilífero variante folicular (CPVF) e a neoplasia folicular não invasiva com características nucleares papilares (NIFTP) (Uno de los mayores dilemas que presenta una muestra de citopatología es el diagnóstico diferencial de las lesiones foliculares tiroideas reunidas como lesiones de patrón folicular, que incluyen: bocio, adenoma folicular [AF], carcinoma folicular (CF), variante folicular del carcinoma papilar [VFCP] y la neoplasia folicular no invasiva con características nucleares de tipo papilar [NIFTP, por su sigla en inglés]. Tais lesões compartilham muitas características, o que faz com que a identificação adequada de lesões foliculares malignas represente um desafio. A citologia obtida através de punção aspirativa por agulha fina (PAAF) é o método padrão mais efetivo para diagnóstico em nódulos de tiroide, mas sua eficácia diagnóstica diminui nitidamente em lesões de padrão folicular da tiroide (La citología por punción y aspiración con aguja fina [PAAF]) es el método estándar más eficaz para el diagnóstico de los nódulos tiroideos, pero su eficacia diagnóstica se ve notablemente reducida en las lesiones de patrón folicular de la tiroides). Assim, uma série de ferramentas auxiliares ao diagnóstico, como a morfometria e a análise de textura nuclear, têm sido utilizadas cada vez mais na prática do patologista, como ferramenta objetiva e reproduzível. São técnicas que dependem da incorporação de softwares para análise digital de imagens e podem agregar acurácia à análise morfológica clássica e à imunohistoquímica na avaliação de lesões de padrão folicular (para el análisis de imágenes digitales y puede agregar precisión al análisis morfológico clásico y la inmunohistoquímica en la evaluación de lesiones de patrón folicular). Somando-se à imunocitoquímica e às técnicas moleculares, a morfometria permite a estimativa de parâmetros identificados em células individuais e representam uma ferramenta que, a partir de parâmetros quantitativos, traduz parâmetros confiáveis para classificação objetiva de malignidade. O objetivo deste estudo é rever as características nucleares e seu papel no diagnóstico de lesões foliculares da tiroide (es revisar las características nucleares y su papel en el diagnóstico de las lesiones foliculares tiroideas).

Abstract One of the biggest dilemmas facing a cytopathology slide is the differential diagnosis of follicular thyroid lesions, grouped as follicular pattern lesions, which include goiter, follicular adenoma (FA) and follicular carcinoma (FC), follicular variant of papillary thyroid carcinoma (FVPTC) and non-invasive follicular thyroid neoplasm with papillary like nuclear features (NIFTP). Such lesions share many characteristics, which makes the proper identification of malignant follicular lesions a challenge. The cytology obtained through fine needle aspiration puncture (FNAB) is the most effective standard method for diagnosis in thyroid nodules, but its diagnostic efficacy clearly decreases in lesions of thyroid follicular pattern. Thus, a series of auxiliary tools for diagnosis, such as morphometry and nuclear texture analysis, have been increasingly used in the pathologist's practice, as an objective and reproducible tool. These are techniques, which depend on the incorporation of software to digital image analysis and can add accuracy to classical morphological analysis and immunohistochemistry in the evaluation of follicular pattern lesions. In addition to immunocytochemistry and molecular techniques, morphometry allows the estimation of parameters identified in individual cells and represents a tool that, based on quantitative parameters, translates reliable parameters for objective classification of malignancy. The aim of this study is to review the nuclear characteristics and their role in the diagnosis of follicular thyroid lesions.

Resumo Introdução: As lesões pigmentadas da mucosa oral podem corresponder a alterações locais ou a manifestações de doença sistémica. Importa conhecer as principais etiologias destas lesões para assim identificar aquelas com necessidade de intervenção e tratamento atempado específico. Descrição do caso: Relata-se o caso de uma mulher de 89 anos que, numa consulta de vigilância de diabetes, refere lesões pigmentadas na língua, com meses de evolução, sem dor ou outra sintomatologia associada. Foi referenciada a consulta de dermatologia para estudo, onde foi realizada biópsia de uma das lesões, cujo resultado foi compatível com mácula melanótica. Perante o quadro clínico e os achados anatomopatológicos foi considerado o diagnóstico de síndroma de Laugier-Hunziker (SLH). A utente foi informada da benignidade do quadro e da ausência de necessidade de tratamento. Comentário: A SLH é uma doença mucocutânea, benigna, de caráter adquirido, que se caracteriza por múltiplas máculas hiperpigmentadas, mais frequentemente presentes na mucosa oral ou lábios e configura um diagnóstico de exclusão. O artigo pretende relatar uma síndroma rara, com manifestação dermatológica, e abordar o diagnóstico diferencial de lesões hiperpigmentadas da mucosa oral.

Abstract Introduction: Pigmented lesions of the oral cavity can be caused by local changes or configure manifestation of systemic disease. It is important to recognize the main etiologies of these lesions in order to identify, timely, the need for intervention and treatment. Case description: We report a case of an 89-year-old woman who, in a diabetes surveillance consultation, complained of the pigmented tongue, with months of evolution, without pain or other associated symptoms. The patient was referred to the dermatologist, where a biopsy of one of the lesions was performed, which revealed a melanotic macula of the oral mucosa. Considering clinical features and histological findings, the diagnosis of Laugier-Hunziker syndrome (LHS) was done. The patient was informed of the benignity of the condition and the absence of the need for treatment. Comment: LHS is a benign mucocutaneous disease, of acquired character, characterized by multiple hyperpigmented macules, most often present in the oral mucosa or lips. Although rare, it is a benign and acquired disease and constitutes a diagnosis of exclusion. The article intends to report a rare syndrome with dermatological manifestations and to address the differential diagnosis of hyperpigmented lesions of the oral mucosa.

Resumo Introdução: Nas últimas duas décadas, a abordagem de tratamento de aneurisma da aorta abdominal (AAA) mudou drasticamente de cirurgia aberta para cirurgia endovascular. A diminuição de cirurgia de AAA convencional , open aneurysm repair (OAR), levanta preocupações relativamente à competência dos futuros cirurgiões vasculares para executar este procedimento complexo e de alto risco. O principal objetivo deste estudo foi avaliar as tendências de tratamento de AAA entre internos de Cirurgia Vascular, ao longo de 15 anos, a nível nacional. Métodos: Identificação dos médicos que terminaram o internato de Angiologia e Cirurgia Vascular entre 2002 e 2017, inclusive, a nível nacional e colheita dos dados através da consulta dos currículos para a prova final de conclusão do internato complementar. Foram avaliados o total de cirurgias por AAA, tanto por OAR e por EVAR e contabilizadas aquelas realizadas como 1º cirurgião. A correlação entre o número de cirurgias abertas de AAA e o ano de conclusão do internato complementar foi testada usando o coeficiente de correlação de Spearman. Resultados: Em Portugal, de 2002-2017, apesar de não se verificar variabilidade no número total de OAR realizados, verificou-se um decréscimo marcado naqueles realizados como 1º cirurgião (rho=-0,363; P<0.02). No final do internato em 2007, um interno de Cirurgia Vascular realizava em média 15 casos de OAR e em 2007 a média foi de apenas 7 casos. Por outro lado, constatou-se um aumento marcado no número total de procedimentos de EVAR (rho=0,478; P<0.02) bem como aqueles realizados como 1ºcirurgião (rho=0,540; P<0.01). Conclusão: O presente estudo revela que os internos de Cirurgia Vascular, a nível nacional, se encontram expostos a progressivamente menos casos de OAR e verifica-se uma diminuição significativa nos procedimentos de OAR como 1º cirurgião.

Abstract Introduction: Surgical site infections are associated with devastating consequences in vascular surgery patients but the data on Methicillin Resistant Staphylococcus aureus (MRSA) infection among those remains scant and conflicting. Most vascular surgery antibiotic prophylaxis assume that all patients submitted to surgery are tested prior to the intervention or that all patients with risk factors for MRSA are presumed to be colonized. However, the costs associated with testing all patients are not negligible, and most of the vascular surgery patients have risk factors for MRSA colonization. The purpose of this study was to evaluate the burden of MRSA clinical infection and its outcome and to adjust clinical practice accordingly. Methods: A retrospective analysis of clinical data from all patients with MRSA isolations that were submitted to vascular surgery in the year 2019 was conducted. The primary endpoint was in-hospital mortality. Secondary endpoints were timing of infection (pre-existent infection or post-surgical infection), need for ICU and length of hospital stay. Results: Out of 1681 patients admitted for surgery in the year 2019 in the vascular surgery ward, only 21 had clinical infection with positive MRSA isolates. All the patients had risk factors for MRSA colonization. Seventeen were admitted for PAD (Rutherford grade 5 or 6). Eight patients had post-operatory infections, whilst the remaining presented with MRSA infection prior to the intervention. Post-operatory infections ranged from superficial incisional in three patients, deep incisional in one patient, and organ/space/prosthesis infection in four patients (of the last group, two had prosthesis infection). There were five deaths, of which two were unrelated to the infection. Of the three deaths probably infection-related, all were post-operatory surgical site infections, and all were organ/space/prosthesis infections (one with prosthesis infection). There was no patient admitted to the ICU that survived. The mean hospital stay was increased by 26 days (31 days, 95% CI, 19-43). Conclusion: Infection by MRSA was less frequent than expected in our population, which may mean that colonization might be smaller than expected. Pre-operative infection was almost always related to chronic wounds and did not increase the risk of post-operative wound infection or death, contrary to post-operative infection, which seems to significantly increase mortality.

Abstract Introduction: Phlegmasia cerulea (PC) is a severe form of deep vein thrombosis. In the setting of massive venous thrombosis and severe ischemia, catheter-directed thrombolysis (CDT) or trombectomy is mandatory. We report three cases of women with PC managed with venous thrombectomy after failure of CDT. Case reports: 1: 20 years-old, with recent intake of oral contraceptive, referred with acute onset of limb swelling, pain and a cold left lower extremity associated with foot pallor, paresthesia and numbness. Doppler ultrasound revealed occlusive thrombosis of the entire deep venous system and the great saphenous vein (GSV). Anticoagulation (AC) and CDT were started. However due to increasing levels of transaminases, creatine kinase and myoglobin, CTD was stopped and venous thrombectomy was proposed. A retrievable inferior vena cava filter (IVC) was implanted and venous surgical trombectomy. The completion venography showed a Cockett compression that was treated with stenting of the left iliac vein. Thrombophilia tests were positive for anticardiolipin antibodies an hyperhomocysteinemia. At 3-years follow-up, the patient is asymptomatic and under AC. The 3-year Doppler showed normal patency for the iliac stent and a mild femoropopliteal vein insuffiency. 2: 19 year-old, taking oral contraceptives, with acute onset of PCD with acute thrombus in the left iliac, femoral, popliteal veins. CDT was started at admittance but stopped after two days because of very low values of serum fibrinogen and persistence of occlusive thrombus in the iliac vein. A retrievable IVC filter was placed and the thrombus removed with surgical thrombectomy. Phlebography showed no significant residual thrombus and no signs of compression were present. At 1 month follow-up, the patient presented without leg edema or venous claudication symptoms. Thrombophilia testing is awaited. 3: 54 year-old who presented with low back pain, worsening left leg pain and swelling with a cyanosed and colder foot. At doppler ultrasound there were monophasic arterial flow in the left leg. After exclusion of arterial embolism, the first therapeutic approach was CDT, but it was also stopped due to very low fibrinogen levels and an ineffective thrombus lysis in venography controls. After implantation of a retrievable IVC, surgical thrombectomy via femoral vein was performed, with successful thrombus removal. Venography showed Cockett syndrome and a stent was implanted. At 6 months the patient remained without major symptoms, and Doppler confirmed stent patency with non residual obstruction or venous insufficiency. Conclusion: Awareness and timely diagnosis of phlegmasia cerulea is necessary to ensure prompt intervention to prevent loss of limb. When CDT is not effective, surgical thrombectomy remains successfully alternative. Iliac venous stenting complement is also crucial to treat associated Cockett syndrome. Endovascular thrombectomy devices may be a reasonable alternative to surgical thrombectomy.

Resumo A molécula paclitaxel está disponível no mercado desde 1991 e está indicada no tratamento de diversas neoplasias. A partir de 2012, a sua utilização foi expandida para dispositivos endovasculares para o tratamento da doença arterial periférica, apresentando-se hoje como uma das principais escolhas no tratamento de lesões arteriais femoro-popliteias sintomáticas, especialmente pelo seu benefício na prevenção de reestenoses. Estes dispositivos apresentam atualmente um benefício comprovado na sobrevida livre de reintervenção e permeabilidade até 5 anos. Uma meta-análise de estudos randomizados revelou um aumento na mortalidade a longo-prazo, no entanto, estudos de coorte com populações mais representativas da prática clinica diária, apresentam resultados discordantes. Salienta-se o facto desta meta-análise ser composta predominantemente por doentes claudicantes, estando os doentes com isquemia crónica com risco de perda de membro sub-representados. Estudos concebidos especificamente para este intuito são necessários para esclarecer este tópico. Por enquanto, os doentes deverão ser alertados para os eventuais riscos e benefícios da exposição a paclitaxel e um processo de decisão conjunta deverá ser um objetivo.

Abstract Paclitaxel molecule has been on the market since 1991 and is indicated for the treatment of multiple neoplasms. Since 2012 has been used in endovascular devices for the treatment of peripheral artery disease and have become a mainstay in the treatment of symptomatic femoro-popliteal lesions, in particular for preventing arterial restenosis. They have a proven benefit in patency and freedom-from re-intervention up to 5 years. A recent meta-analysis of RCT showed an increased late-mortality rate, however, real-life cohorts analyses presents contradictory results. RCT meta-analysis is comprised mainly by claudicants, and CLTI patients are underrepresented. Further studies are needed to clarify this matter, in particular with a higher percentage of CLTI presentation. For now, patients should be advised about risks and benefits of paclitaxel exposure and a shared decision-making process should be followed.

Resumo Introdução: A endoprótese Nellix® (Endologix Inc., Irvine CA) é composta por dois stents expansíveis por balão envolvidos por endobags preenchidos por um polímero, obliterando assim o saco aneurismático - Endovascular Aneurysm Sealing (EVAS). Inicialmente, pelas suas propriedades, foi introduzida com instruções para uso (IFU) alargadas, possibilitando a utilização em Aneurismas da Aorta Abdominal (AAA) de anatomia mais complexa. Porém, durante a experiência com esta endoprótese, foi descrito um elevado número de complicações, levando à restrição progressiva das IFU. Atualmente, o seu uso livre foi descontinuado e apenas está disponível em centros selecionados e para efeitos investigacionais. O objetivo deste estudo é reportar os resultados institucionais da utilização da endoprótese Nellix® no contexto de AAA. Material e Métodos: Realizou-se um estudo retrospectivo referente a doentes tratados a AAA utilizando a endoprótese Nellix® numa instituição terciária universitária. Foram incluídos todos os casos eletivos e urgentes, identificados através da consulta de registos clínicos da instituição. Foram excluídos casos de aneurisma toraco-abdominal. Os dados referentes às características de base, procedimento realizado, curso do internamento e seguimento pós hospitalar foram obtidos por consulta dos processos clínicos. Foram analisados como endpoints o sucesso técnico e clínico aos 30 dias, assim como complicações e intervenções secundárias a médio e longo prazo. Resultados: Entre 2015 e 2017, a esta endoprótese foi utilizada em 12 doentes, 9 homens e 3 mulheres, com média de 71(±8) anos. As comorbilidades mais frequentemente associadas foram HTA (n=12), tabagismo (n=7), cardiopatia isquémica (n=7), DAOP (n=6) e DRC (n=6). Em todos os doentes a indicação foi aneurisma primário degenerativo, com uma excepção, cuja indicação foi a presença de endoleak (EL) tipo 1a pós-EVAR prévio. Dez doentes foram submetidos a cirurgia eletiva e dois a cirurgia urgente, ambos por aneurisma sintomático. Três eram aneurismas aortoilíacos e os restantes aórticos (n=9), sendo que 3 tinham envolvimento de pelo menos uma artéria renal. Nove doentes foram submetidos a EVAS sem procedimentos complementares; os restantes a EVAS com chimney (ChEVAS) para as renais e/ou artéria mesentérica superior (n=3). O diâmetro médio pré-operatório era de 57mm (±6.5mm). Num doente tratou-se concomitantemente um aneurisma popliteu através do implante de stent coberto. Aos 30 dias verificou-se o óbito em 2 doentes submetidos a ChEVAS. As complicações mais frequentes foram Insuficiência Respiratória (n=3) e LRA com necessidade de diálise (n=3), sendo que em dois houve oclusão intencional das artérias renais (doentes com DRC terminal em pré-diálise). Neste período, houve uma reintervenção, por isquémia aguda de membro por trombose aguda de stent popliteu, tratada com sucesso com trombólise dirigida por catéter.Após os 30 dias, verificou-se o óbito em 4 doentes (sobrevivência aos 2 anos de 60%, SE=.154). As complicações verificadas foram EL tipo 1a (n=3), EL 1b (n=1) e trombose de stent aórtico (n=1). Dois doentes foram submetidos a intervenção secundária: um submetido a pontagem femoro-femoral cruzada por trombose de stent e outro a explantação protésica e reconstrução in-situ através de pontagem aorto-bifemoral. No último, verificou-se o óbito no pós-operatório precoce. Dois doentes aguardam intervenção secundária por EL tipo 1a e crescimento do saco. O diâmetro médio do saco aneurismático no último exame ou pré-intervenção secundária era 59mm (±10.6mm). O tempo médio de follow-up é de 2.3(±1.6) anos. Conclusões: Na nossa instituição, a utilização da endoprótese Nellix® está associada a elevada taxa de complicações perioperatórias e a médio prazo, com elevada taxa de complicações relacionadas com o aneurisma, sendo o EL tipo 1a a mais frequente. Apesar de atualmente o uso livre da endoprótese estar descontinuado, os doentes que foram submetidos previamente a EVAS carecem de um plano de vigilância específico e mais intensivo, para deteção e correção atempada de complicações.

Abstract Introduction: Nellix® endoprosthesis (Endologix Inc., Irvine, CA) is composed by two ballon-expandable stents surrounded by endobags, which are filled with a polymer, thus obliterating the aneurysmal sac - Endovascular Aneurysm Sealing (EVAS). Initially, due to its properties, was introduced with extended IFU, allowing the use in more complex abdominal aortic aneurysms. However, during the initial experience with this endoprosthesis, a high number of poor outcomes have been described, leading to the progressive restriction of IFU. Currently, it has been discontinued and is only available in selected centers for clinical research purposes. Our study aim to report the institutional results of the use of the Nellix® endoprosthesis in the treatment of AAA. Material and Methods: A retrospective study was designed, including patients with AAA treated with Nellix® endoprosthesis treated at a universitary tertiary care facility. Elective and urgent patients we&apos;re included, and patients we&apos;re identified through the institutional files. Thoraco-abdominal aneurysm we&apos;re excluded. Data about baseline characteristics, surgery, hospitalization course and follow-up post discharge was obtained by consulting personal clinical files. Primary endpoints are technical and clinical success at 30 days, as complications and secondary interventions at mid and long-term. Results: Between 2015 and 2017, this endoprosthesis was used in 12 patients, 9 male and 3 female, with a mean age of 71 (±8) years. The most common comorbidities associated we&apos;re hypertension (n=12), current or former tobacco use (n=7), coronary heart disease (n=7), peripheral artery disease (n=6) and chronic kidney disease (n=6) In all patients, the treatment indication was primary degenerative aneurysm, with one exception, which was the presence of type 1a EL after EVAR. Ten patients underwent elective and 2 urgent surgery due to symptomatic aneurysm. Three we&apos;re aortoiliac aneurysms and the remaining aortic aneurysms (n=9) with three having involvement of at least one renal artery. Nine patients underwent conventional EVAS; the remaining EVAS with chimney (ChEVAS) for the renal artery(ies) or superior mesenteric artery (n=3). The average preoperative diameter was 57(±6.5) mm. One patient was simultaneously submitted to endovascular repair of a popliteal artery aneurysm with covered stent. By 30 days, death occurred in 2 patients, all submitted to ChEVAS. The most common post-operative complications we&apos;re respiratory failure (n=3), AKI with dialysis (n=3), being that in two patients there was intentional covering of the renal arteries (patients with pre-dialysis CKD). In this time frame, we verified one reintervention: catheter-directed thrombolysis for acute limb ischemia due to popliteal covered stent thrombosis. After 30 days, 4 deaths occured (2 year survival 60%, SE 0.154). The most common complications were type 1a EL(n=3), type 1b EL(n=1) and aortic stent thrombosis (n=1). Two patients have already been reintervened: one submitted to femoro-femoral crossover bypass and the other to surgical endoprosthesis explantation and in situ reconstruction aortobifemoral bypass. The last was deceased in the early postoperative period. Two patients are waiting reintervention for type Ia EL and aneurysmal sac growth. The average sac diameter in last follow-up or before secondary intervention was 59(±10.6) mm. Mean follow-up time is 2,3(±1,6) years. Conclusions: In our institution, the use of Nellix® endoprosthesis is associated with a high rate of perioperative morbidity and mid to long-term aneurysm-related complications, being type Ia EL the most common. Although the free use of the endoprosthesis is currently discontinued, patients who have previously undergone EVAS lack a specific and more intensive surveillance plan for the timely detection and correction of complications.

Resumo Introdução: A doença do coronavírus de 2019 (COVID-19) e consequente período de confinamento teve um impacto significativo no sistema nacional de saúde, com restrições em toda a actividade clínica - actividade assistencial na consulta, exames complementares de diagnóstico e número e tipo de intervenções cirúrgicas. A apreensão dos doentes em recorrer aos cuidados médicos e aos hospitais levou a admissões tardias, e na nossa percepção, a apresentações mais graves da patologia de base, nomeadamente na Isquémia Crítica de Membro (ICM). A necessidade de testar os doentes previamente a uma cirurgia não-emergente aumentou o tempo de referenciação inter- e intra-hospitalar, o que, somando à diminuição dos tempos cirúrgicos e da disponibilidade de vagas em unidades de cuidados intensivos, potencialmente prejudicou os resultados. O objectivo deste estudo é avaliar objetivamente o tipo de patologia que foi tratado durante o estado de emergência e comparar o desfecho dos procedimentos cirúrgicos com o mesmo período em 2018 e 2019. Métodos: Foi realizada uma análise retrospectiva dos processos clínicos dos doentes submetidos a cirurgia nos meses de Março e Abril do ano de 2020 e foi feita a comparação com o mesmo período dos dois anos prévios. O endpoint primário foi mortalidade aos 30 dias ou intra-hospitalar. Os endpoints secundários foram classificação patológica e do grau de isquémia, taxa de amputação, nível de amputação, tipo de cirurgia (aberta, endovascular ou híbrida), tempo de internamento e re-intervenção. Resultados: Foram operados 98 doentes no Período COVID (PC) comparado com 286 no Período Não-COVID (PNC). Não houve diferenças estatisticamente significativas na idade (70 anos (17-98) no PC vs. 69 (17-92) no PNC, p=.13) ou sexo dos doentes operados (76% masculino (n=74) no PC vs. 70% (n=196) no PNC, p=.26). Também não houve diferença estatisticamente significativa na mortalidade (5% (n=5) no PC vs. 5% (n=13) no PNC, p=.88). Houve uma diminuição estatisticamente significativa da cirurgia aberta (43% (n=42) no PC vs. 57% (n=164) no PNC, p=.04). Não houve diferenças significativas no tempo de internamento hospitalar (10 (0-77) dias no PC vs. 7 (0-118) no PNC, p=.6) e na taxa de re-intervenção (18% (n=18) no PC vs. 16% (n=45) no PNC, p=.58). A Doença Arterial Periférica (DAP) correspondeu a 75% (n=73) das admissões no PC, vs. 48% (n=137) no grupo PNC (p=.02). A ICM correspondeu a 99% (n=70) das admissões por DAP no PC, vs. 93% (n=114) no PNC (p=.1), com um aumento significativo da proporção de doentes cuja apresentação na admissão foi de grau 5 ou 6 de Rutherford (81% (n=57) vs. 68% (n=77), p=.03). Houve ainda uma diminuição sem significado estatístico da taxa de amputação (35% (n=25) no PC vs. 40% (n=49) no PNC, p=.49) com um aumento não significativo da taxa de amputação major (52% (n=13) no PC vs. 39% (n=19) no PNC, p=.27). O segundo grupo de patologia mais tratado foi a doença aneurismática da aorta e artérias ilíacas, mas houve uma diminuição estatisticamente significativa do número de doentes tratados (5% (n=5) no PC vs. 13% (n=36) no PNC, p=.05). Todos os aneurismas da aorta tratados durante o PC estavam em rotura (100% (n=5) vs. 42% (n=15) in the NCP, p=0.2). Não houve diferenças significativas entre os grupos na mortalidade por reparação urgente de aneurismas (60% (n=3) no PC vs. 47% (n=7) no PNC, p=.77). Conclusão: As restrições impostas pela COVID-19 manifestaram-se principalmente no tipo de patologia tratado e no número de doentes operados. A apresentação mais grave da patologia de base, manifestada por graus de isquémia crítica mais avançados, não aumentou a mortalidade nem se reflectiu de forma significativa nas taxas de amputação. A doença aneurismática da aorta foi a segunda patologia mais tratada, mas com uma diminuição significativa do número total de casos, sem diferença significativa na mortalidade.

Abstract Introduction/Objectives: The Corona Virus Disease of 2019 (COVID-19) has taken a major toll on the public health system, with restrictions in all clinical activity, from consultations and exams to number and type of surgeries. Patients apprehension to resort to medical aid and hospitals leads to late admissions and, in our perception, more severe presentations of the underlying pathology, namely, in Chronic limb threatening ischemia (CLTI). Need for testing prior to non-emergent surgery causes larger delays in the referral of patients, and this, added to the reduction of surgical times and ICU availability, potentially results in worse outcomes. The aim of this study was to objectively evaluate the type pathology that was treated during the emergency state and to compare the outcome of the surgical procedures with the same period of 2018 and 2019. Methods: A retrospective analysis of the patient charts from patients submitted to surgery in the months of March and April of the year 2020 was conducted and compared to the same period on the previous two years. The primary endpoint was death at 30 days or during hospital stay and the secondary endpoints were pathology classification, grade of ischemia, amputation, amputation level, type of surgery (endovascular, conventional or hybrid), time of hospital stay and reintervention. Results: There were 98 patients submitted to surgery in the COVID period (CP), compared to 286 in the Non-COVID period (NCP). There was no significant difference in the age (70 years (17-98) in the CP vs. 69 (17-92) in the NCP, p=.13) or sex profile of the patients (76% male (n=74) in the CP vs. 70% (n=196) in the NCP, p=.26). There was no statistical difference in mortality (5% (n=5) in the CP vs. 5% (n=13) in the NCP, p=.88). There was a statistically significant decrease in conventional surgery (43% (n=42) in the CP vs. 57% (n=164) in the NCP, p=.04), but no statistically significant difference in length of hospital stay(10 (0-77) days in the CP vs. 7 (0-118) in the NCP, p=.6), and reintervention (18% (n=18) in the CP vs. 16% (n=45) in the NCP, p=.58). PAD corresponded to 75% (n=73) of the admissions in the CP vs. 48% (n=137) in the NCP, p=.02. CLTI corresponded to 99% (n=70) of the PAD population in the CP, vs. 93% (n=114) in the NCP, p=.1, with a significant increase in the number of patients presenting with Rutherford Grades 5 and 6 (81% (n=57) in the CP, vs. 68% (n=77) in the NCP, p=.03). There was a non-significant decrease in amputation rate (35% (n=25) vs. 40% (n=49), p=.49) and increase of major limb amputation (52% (n=13) vs. 39% (n=19), p=.27). The second most frequent pathology was aneurysmal aortic and iliac disease, but there was a statistically significant reduction in the number of patients treated (5% (n=5) in the CP vs. 13% (n=36) in the NCP, p=.05). All aortic aneurysms treated in 2020 were ruptured (100% (n=5) vs. 42% (n=15) in the NCP, p=0.2). There was no significant difference in mortality in urgent aortic aneurysm repair between groups (60% (n=3) in the CP vs. 47% (n=7) in the NCP, p=.77). Conclusions: COVID-19 restrictions manifested mainly in the type of pathology treated and the number of patients operated on. The gravity of the underlying pathology, manifested by more serious wounds and advanced CLTI at presentation, did not increase mortality nor was reflected on limb amputations rates. Aortic and iliac aneurismal disease was the second most common pathology treated but with a significant decrease in total number of cases and no significant difference in mortality.