Resumo A partir de uma pesquisa-ação em um território quilombola, apreendeu-se a Acessibilidade Cultural Participativa enquanto um modo de agir específico em desenvolvimento local, a fim de garantir a cidadania cultural de pessoas com deficiência em ambientes de produção cultural de base territorial-comunitária. A Acessibilidade Cultural Participativa considera a deficiência uma dimensão estética, que exige mudanças cognitivas sobre as leituras e intervenções nas realidades participativas do território. pesquisaação pesquisa ação quilombola apreendeuse apreendeu se local territorialcomunitária. territorialcomunitária territorial comunitária. comunitária territorial-comunitária estética

Resumen A partir de una investigación-acción en un territorio quilombola, se aprendió la Accesibilidad Cultural Participativa como una forma específica de actuar en el desarrollo local, con el fin de garantizar la ciudadanía cultural de las personas con discapacidad en entornos de producción cultural territorial-comunitaria. La Accesibilidad Cultural Participativa considera la discapacidad como una dimensión estética, que requiere cambios cognitivos en las lecturas e intervenciones en las realidades participativas del territorio. investigaciónacción investigación acción quilombola local territorialcomunitaria. territorialcomunitaria territorial comunitaria. comunitaria territorial-comunitaria estética

Abstract Through an action-research conducted in a quilombola territory, we learned about Participatory Cultural Accessibility as a specific way of acting in local development, in order to guarantee the cultural citizenship of people with disabilities in cultural-community-based environments of cultural production. Participatory Cultural Accessibility views disability as an aesthetic dimension, which requires cognitive changes in the readings and interventions in the participatory realities of the territory. actionresearch action research territory development culturalcommunitybased community based production dimension

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.

Abstract Introduction: Endovascular aneurysm repair (EVAR) offers significant advantages on aneurysm treatment. However, the management of EVAR complications or failure often results in complex surgical approaches, sometimes requiring graft explantation which remains a major challenge and one associated with a high morbidity and mortality. The purpose of this study is to review our contemporary institutional experience with EVAR explantation. Methods: An institutional administrative database was reviewed to identify patients who were subject of graft explantation following standard infra-renal EVAR between 2011 and 2021. Follow-up was extracted from patient charts. The primary endpoint was perioperative mortality (30-days or in-hospital). Demographics, indications for explantation and procedure details were evaluated. Results: Over a 10-year period, between 2011 and 2021, there were 617 standard primary EVAR procedures performed in our institution for infrarenal aortic aneurysms. During this period, we identified 13 patients submitted to EVAR explantation, two of which were referrals from other vascular centers. All patients were male and mean age at explantation was 71 years (range 47-81). The primary EVAR procedure took place 29 months (range 0-72) before explantation. The primary indication for EVAR was ruptured aortic aneurysm in seven patients. The majority of explantation operations were emergent (6/13, three due to unstable aorto-enteric fistula (AEF), three due to rupture) or urgent (4/13, two stable AEF, two graft infections). In 3 cases, explantation was elective (two type Ia endoleaks and one type II endoleak with sac expansion). None of the patients had been submitted to a previous attempt at endovascular salvage. All patients were submitted to transperitoneal approaches, and all required initial supracoeliac or suprarenal aortic clamping. After explantation, in situ reconstruction was performed in eight patients, six of which with complete EVAR explantation and two with partial EVAR explantation. Two in situ reconstructions were made using superficial femoral veins, and the remaining used prosthetic grafts. Aortic ligation and extra-anatomic bypass were performed in five cases, The 30-day mortality was 54% (seven patients) with 33% of mortality for elective repair, 50% mortality for urgent repair, and 67% mortality for emergent repair. Mean hospital stay after surgery was 48 days for survivors. Mean survival after discharge was 10 months. Conclusion: EVAR explantation is still a relatively rare and particularly complex procedure. When the reason for explantation is graft infection and AEF, and when performed in an emergent context, it is a particularly morbid procedure with a dismal prognosis. As the number of endovascular aneurysm repairs increase, our global experience will become increasingly important in bettering our surgical and clinical outcomes.

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.

Abstract In August 2019, the Northeast coast of Brazil was impacted by an extensive oil spill, with immediate effects on marine and coastal ecosystems and significant impacts on tourism and food security. The human dimension of those impacts also includes the loss of cultural ecosystem services (CES); the non-material benefits stemming from strongly rooted cultural practices and relationships with nature. CES are of great importance for local residents and visitors that flock to Brazilian iconic beaches, however, they are difficult to measure using traditional assessment methods due to their subjective and non-tangible nature. Here, we use a big data approach to assess and map the loss of CES in the Northeast coast of Brazil caused by the recent oil spill. We analysed 2,880 digital images (published on the image sharing platform Flickr) taken before and during the disaster in affected locations, using a combination of automated techniques. Results showed a sharp decline in the number of users posting photos of locations affected by oil spill, and a decline in photos representing landscape and cultural appreciation. Our big data approach provides a fast and automated way to assess CES at large spatial scales that can be used to monitor the social impacts of environmental disasters.

Abstract Social media data is a rich source of information to assess human activities in catastrophic events. Here, we use social media data to understand how the 2019 Brazilian oil spill influenced social attitudes. Data were collected from the globally popular Instagram platform between August 1, 2019 and March 1, 2020. First, we manually identified the 5 most popular (portuguese language) hashtags related to the oil spill #oleonononordeste; #desastreambiental; #marsemoleo; #sosnordeste; #marsempetroleo. In the sequence, we collected information on captions, post metadata and users associated with posts retrieved using the selected hashtags. We identified a total of 7,413 posts. These posts were grouped in topics: government (47.76%), protest (24.37%), volunteers (24.45%), biodiversity (0.003%), origin (0.006%), tourism (0.008%) and others (0.016%). All topics had the peak of posts in October and November 2019. Nevertheless, interest in the oil spill was temporary, with most posts appearing in the 2-4 months after the beginning of the disaster. Our findings illustrate the enormous potential of using social media data for understanding and monitoring human engagement with environmental disasters, but also suggest that conservationists and environmental groups may only have a limited ‘window of opportunity’ to engage and mobilize public support for remediation and restoration efforts.

BACKGROUND: The contemporary perspectives of occupational therapy in Latin America focus on an epistemic, political, and plural field under construction and in dispute. It is about the notions of knowing and doing designed to appoint the theoretical and methodological aspects that support the reading and intervention of the complex realitiesPURPOSE: This paper explores a glocal dialogue about the production and dissemination of knowledge in occupational therapy in Latin AmericaKEY ISSUES: The dialogue includes issues and trends in the global scientific and social scenario, without neglecting aspects of different local realities around the world. By focusing on the profession in Latin America, using different perspectives, such as Critical Occupational Therapy; Occupational Therapy and Social Issues; Occupational Therapy and Culture; Territory and Community Occupational Therapy; Southern Occupational Therapies; and Occupational Science in Latin America. It further discusses the relationship between the theoretical perspectives and the coloniality of knowledge in occupational therapy and the contradictions based on neoliberal models in the production and dissemination of knowledgeCONCLUSION: The hegemonic neoliberal model and the glocalisation theoretical framework appeared to support and circumvent the production of scientific knowledge in occupational therapy, and placed Latin America on the periphery of the global debate

Resumo Introdução: As consequências psicopatológicas e na qualidade de vida da DVC podem ser significativas, particularmente nos estadios mais avançados. As perturbações da ansiedade e do humor já estão frequentemente presentes no doente que procura o cirurgião vascular por DVC. O objetivo deste estudo foi identificar e caracterizar a psicopatologia na DVC e a sua relação com a qualidade de vida. Métodos: Estudo transversal que incluiu todos os doentes observados em primeira consulta de dois cirurgiões vasculares de um hospital universitário terciário, com o diagnóstico de DVC, de Dezembro de 2019 a Janeiro de 2021. Após realização da consulta, foram aplicados 5 questionários validados na língua portuguesa: EQ-5D (Euro quality of life - 5 Dimensions), EQVAS (Euro QoL visual analogue scale), CIVIQ20 (chronic venous insufficiency questionnaire), BAI (Beck Anxiety Inventory) e BDI (Beck&apos;s Depression Inventory). Os endpoints primários foram os scores sugestivos de perturbações da ansiedade e de humor, avaliadas nos questionários BAI e BDI, respetivamente. Os endpoints secundários foram a qualidade de vida, avaliada nos questionários EQ-5D, EQVAS e CIVIQ20. Os achados foram correlacionados com a classe clínica (C) da classificação CEAP (clinical, etiological, anatomical and pathophysiological). Resultados: Foram incluídos 59 doentes. A idade mediana foi de 58 anos. 73% eram do sexo feminino. 20% realizava previamente medicação psiquiátrica. A distribuição na classificação clínica CEAP foi a seguinte: C1 7%; C2 64%; C3 10%; C4 15%; C5 2%; C6 2%. O score CIVIQ20 mediano foi de 48 e a pontuação mediana na escala EQVAS foi de 75. O score mediano BAI foi 16, com 40% dos doentes a relatarem níveis moderados ou potencialmente preocupantes de ansiedade; o score mediano BDI foi 7, com 31% dos doentes a relatarem níveis pelo menos ligeiros de depressão. Verificou-se uma correlação positiva entre a classe clínica CEAP e o score BAI (p=0,049) e o score BDI (p=0,039). Não se verificou correlação entre a classe clínica CEAP e a pontuação na EQVAS. Doentes com score CIVIQ20 superior selecionaram pontuações inferiores na EQVAS (p<0,001). Verificou-se uma correlação positiva entre o score CIVIQ20 e o score BAI (p<0,001) e o score BDI (p=0,003). Doentes com pior saúde percecionada na EQVAS apresentaram scores superiores de ansiedade (p=0,009) e de depressão (p<0,001). Verificou-se uma correlação positiva entre o score BAI e o score BDI (p=0,002). Conclusão: As perturbações da ansiedade e do humor coexistem frequentemente e são prevalentes nos doentes com DVC sintomática. A relação entre sinais clínicos graves de DVC, qualidade de vida inferior e presença de psicopatologia foi demonstrada neste trabalho, que sugere a necessidade de uma abordagem psicológica adjuvante nos doentes com DVC.

Abstract Introduction: Chronic venous disease (CVD), particularly if severe, can have significant psychopathologic consequences and major changes in quality of life. Anxiety and humor disturbances are often already present when the patient with CVD searches the vascular surgeon. This study aims to identify and characterize psychopathology in CVD and its relation with quality of life. Methods: A transversal study included all patients seen in the first appointment with two vascular surgeons of a tertiary university hospital, with the CVD diagnosis, from December 2019 to January 2021. Five Portuguese language-validated questionnaires were used: EQ-5D (Euro quality of life - 5 Dimensions), EQVAS (Euro QoL visual analogue scale), CIVIQ20 (chronic venous insufficiency questionnaire), BAI (Beck Anxiety Inventory) and BDI (Beck&apos;s Depression Inventory). The primary endpoints were anxiety and humor disturbances’ suggestive scores, evaluated on BAI and BDI questionnaires, respectively. The secondary endpoints were quality of life, evaluated on EQ-5D, EQVAS and CIVIQ20 questionnaires. The findings were correlated according to the clinical class (C) of the CEAP classification (clinical, etiological, anatomical and pathophysiological). Results: Fifty-nine patients were included. The median age was 58 years. 73% were female. 20% was under psychiatric pills. The CEAP clinical classification was as follows: C1 7%; C2 64%; C3 10%; C4 15%; C5 2%; C6 2%. The median CIVIQ20 and EQVAS scores were 48 and 75, respectively. The median BAI score was 16; 40% of the patients stated moderate or potentially worrying anxiety levels. The median BDI score was 7; 31% of the patients stated at least mild levels of depression. There was a positive correlation between the clinical class CEAP and the BAI score (p=0,049) and the BDI score (p=0,039). There was no correlation between the clinical class CEAP and the EQVAS score. The patients with higher CIVIQ20 scores have chosen lower scores on EQVAS (p<0,001). There was a positive correlation between the CIVIQ20 score and BAI score (p<0,001) and the BDI score (p=0,003). The patients with worse ascertained health on EQVAS displayed higher anxiety (p=0,009) and depression scores (p<0,001). There was a positive correlation between BAI and BDI scores (p=0,002). Conclusion: Anxiety and depression disturbances commonly coexist and are prevalent in symptomatic CVD patients. The relation between severe clinical signs of CVD, lower quality of life and the presence of psychopathology was demonstrated in this study, which suggests the need for an adjunctive psychological approach to CVD patients.

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.

Resumo Introdução: O traumatismo fechado da aorta (TFA) é uma causa major de mortalidade no trauma de alta velocidade. Embora a maior parte dos casos resulte em morte instantânea, o TFA pode estar presente em doentes politraumatizados e um elevado índice de suspeição é necessário. O tratamento endovascular oferece vantagens significativas e é actualmente o standard of care. O objectivo deste estudo é avaliar a nossa experiência institucional no tratamento endovascular do TFA. Métodos: Foi feita uma análise retrospectiva dos dados de alta dos doentes admitidos por TFA entre os anos de 2010 e 2019 da base de dados administrativa da nossa instituição (centro de trauma de nível 1). Foi usado o código de procedimento 39.73 - implantação endovascular de enxerto na aorta torácica e cruzado com os registos hospitalares para identificar todos os casos de TFA. Os dados de seguimento foram retirados dos processos clínicos. Os endpoints primários foram primary technical and clinical success. Os endpoints secundários foram tempo para o diagnóstico e para tratamento cirúrgico relativamente ao evento traumático, mortalidade, ongoing primary clinical success, e detalhes do procedimento (revascularização do membro superior, drenagem de líquido cefalorraquidiano, heparinização sistémica, oversizing). Resultados: Identificámos seis doentes com TFA que foram submetidos a TEVAR entre 2010 e 2019. Todos foram vítimas de trauma de desaceleração de alto impacto, tinham idades entre os 24 e os 57 anos, e eram previamente saudáveis. Lesões major estavam presentes em todos (Injury Severity Score 14-57). Todos os doentes foram submetidos a AngioTC à admissão, o que permitiu o diagnóstico precoce e o tratamento em menos de 24 horas em todos excepto um (que foi tratado nas primeiras 48 horas). Lesões de grau III estavam presentes em todos os doentes. Todos os doentes foram submetidos a TEVAR com 100% de primary technical and clinical success. Três doentes tinham lesões que se estendiam acima da artéria subclávia, pelo que foi necessária exclusão da mesma, mas nenhum doente foi submetido a revascularização do membro superior. Não foi usada drenagem de líquido cefalorraquidiano em nenhum doente e não houve eventos neurológicos. Metade dos doentes foram submetidos a heparinização sistémica durante o procedimento. O oversizing médio foi de 16% (10-35%). Não houve mortalidade hospitalar nem mortalidade durante o follow-up (duração média de 35,5 meses com IIQ de 84,5 meses) e o ongoing primary clinical success é de 100%. Conclusão: O tratamento endovascular é seguro e eficaz para os casos de TFA, mesmo em doentes politraumatizados, e são expectáveis bons resultados a médio prazo. As especificações do procedimento tal como a necessidade de revascularização do membro superior, uso de drenagem de líquido cefalorraquidiano, oversizing e heparinização sistémica ainda não estão bem definidas. As consequências a longo prazo ainda necessitam clarificação.

Abstract Introduction: Traumatic Thoracic Aortic Injury (TTAI) is a major cause of mortality in high-velocity trauma. While most cases result in instant death, TTAI may be present in patients with multiple traumatic injuries and therefore a high index of suspicion is necessary. Endovascular treatment offers significant advantages in this context and is now standard of care. The purpose of this study is to review our contemporary institutional experience with endovascular repair of TTAI. Methods: A retrospective analysis of discharge data for patients admitted with TTAI between 2010 and 2019 was performed from our institutional administrative database (level 1 trauma center). We extracted ICD-9 procedure code 39.73 - endovascular implantation of graft in the thoracic aorta and cross-checked with hospital registries to identify all TTAI cases. Follow-up was extracted from patient charts. The primary endpoints were primary technical and clinical success. Secondary endpoints were time to diagnosis and to surgical procedure relative to traumatic event, overall mortality, ongoing primary clinical success, and procedural details (upper limb revascularization, spinal drainage, systemic heparinization and endograft oversizing). Results: We identified six patients with TTAI who underwent TEVAR between 2010 and 2019. All were victims of high impact deceleration trauma, aged between 24 and 57 years old, and otherwise healthy. Additional major injuries were present in all patients (Injury Severity Score 14-57). All patients were submitted to CTA at admission which allowed for early diagnosis of TTAI and treatment in less than 24 hours in all cases expect one (which was treated in the first 48 hours). Grade III lesions were present in all six patients. All patients underwent TEVAR with 100% technical and clinical success. Three patients had a lesion that extended above the subclavian artery and consequently required subclavian coverage, but no patient was submitted to upper limb revascularization. Spinal drainage was not used in any case and there were no neurologic events. Half the patients were submitted to the procedure under systemic heparinization. The median oversizing of the endograft was 16% (10-35%). There was no in-hospital mortality nor mortality during follow-up (median duration of 35,5 months with an IIQ of 84,5 months) and the ongoing primary clinical success is 100%. Conclusion: Endovascular repair is a safe and effective therapy for TTAI even in patients with multiple trauma, and good mid-term results are expected. The procedure specifications such as the need for upper limb revascularization, use of spinal drainage, endograft oversizing, and systemic heparinization are still unclear. The long-term consequences need to be clarified.

Resumo Introdução: A doença cardíaca pode causar diminuição da perfusão sistémica e comprometer o inflow para procedimentos de revascularização de membro inferior, diminuindo a sua permeabilidade a curto e médio prazo. É possível que os doentes com doença valvular cardíaca ou redução da fração de ejeção do ventrículo esquerdo (FEVE) tenham piores resultados após revascularização dos membros inferiores. Métodos: Este estudo retrospetivo incluiu todos os procedimentos iniciais de revascularização de membro inferior realizados num hospital terciário, entre Janeiro de 2017 e Dezembro de 2018, em doentes com DAP diagnosticada e um ecocardiograma transtorácico (ETT) pré-operatório. O grupo com doença cardíaca moderada a grave no ETT (Grupo 1, definido como FEVE<40% ou doença valvular cardíaca moderada a grave) foi comparado com o grupo com doença cardíaca ligeira ou ausente (Grupo 2, definido como FEVE≥40% e doença valvular ligeira ou ausente). Foi realizada análise de subgrupo considerando a presença e gravidade da alteração específica no ETT. O endpoint primário foi amputação major e os endpoints secundários foram restenose/oclusão diagnosticada, reintervenção vascular e sobrevida. Resultados: O estudo incluiu 268 procedimentos de revascularização de membro inferior. Os Grupos 1 e 2 incluíram 70 e 198 procedimentos, respetivamente. A prevalência de isquémia crónica com compromisso de membro (ICCM) foi de 89% em ambos os grupos. Não se verificou diferença significativa entre os grupos na gradação de ferida e infeção (no sistema WIfI) e no estadiamento anatómico da doença (no sistema GLASS). O Grupo 1 incluiu 73% procedimentos endovasculares (65% no Grupo 2; p=0,34). As taxas de amputação nos Grupos 1 e 2 foram 9% e 13% a 1 mês, 19% e 20% a 1 ano e 19% e 22% a 2 anos, respetivamente (p=0,758). As taxas de restenose/oclusão diagnosticada nos Grupos 1 e 2 foram 5% e 15% a 1 mês, 18% e 26% a 1 ano e 24% e 31% a 2 anos, respetivamente (p=0,119). As taxas de reintervenção nos Grupos 1 e 2 foram 13% e 18% a 1 mês, 25% e 27% a 1 ano e 30% e 32% a 2 anos, respetivamente (p=0,614). Após estratificação em subgrupos de acordo com a presença e gravidade da alteração cardíaca específica, as diferenças para os outcomes acima apresentados permaneceram não significativas. A sobrevida global nos Grupos 1 e 2 foi de 92% e 96% a 1 mês, 61% e 86% a 1 ano e 52% e 80% a 2 anos, respetivamente (p<0,001). A presença de FEVE<40% associou-se a pior sobrevida (p<0,001), tal como a presença de doença valvular cardíaca moderada a grave (p=0,004). Conclusão: O nosso estudo sugere que a doença cardíaca moderada a grave, definida no ETT, não influencia os outcomes relacionados com o membro após procedimentos de revascularização. Contudo, os doentes com doença cardíaca valvular ou redução da FEVE têm pior sobrevida. Não devemos assumir que os doentes cardíacos têm piores outcomes relacionados com o membro, mas devemos providenciar prevenção terciária agressiva para melhorar o seu prognóstico vital.

Abstract Introduction: Inadequate systemic perfusion as a consequence of heart disease may compromise inflow to lower limb revascularization procedures, decreasing short and mid-term patency. It may be theorized that patients suffering from heart valve disease or reduction of left ventricular ejection fraction (LVEF) have worse limb outcomes after lower limb revascularization. Method: This retrospective study included all first lower limb revascularization procedures performed in a tertiary hospital, between January 2017 and December 2018, in patients with diagnosed PAD and an available preoperative transthoracic echocardiogram (TTE). The group with moderate to severe heart disease in TTE (Group 1, defined as LVEF<40% or moderate to severe valvular heart disease) was compared against the group with no or mild heart disease in TTE (Group 2, defined as LVEF≥40% and no or mild valvular heart disease). Subgroup analysis was undertaken considering the presence and severity of the individual heart change on TTE. Primary endpoint was major amputation, and secondary endpoints were diagnosed restenosis/occlusion, vascular reintervention and overall survival. Results: The study included 268 lower limb revascularization procedures. Group 1 and 2 included 70 and 198 procedures, respectively. In both groups, the prevalence of CLTI was 89%. There were no significant differences in wound and infection grading (in WIfI), and anatomic disease staging (in GLASS), between Groups 1 and 2. In Group 1, 73% were endovascular procedures (65% in Group 2; p=0,34). Amputation rates in Group 1 and 2 were 9% and 13% at 1 month, 19% and 20% at 1 year and 19% and 22% at 2 years, respectively (p=0,758). Diagnosed restenosis/occlusion rates in Group 1 and 2 were 5% and 15% at 1 month, 18% and 26% at 1 year and 24% and 31% at 2 years, respectively (p=0,119). Reintervention rates in Group 1 and 2 were 13% and 18% at 1 month, 25% and 27% at 1 year and 30% and 32% at 2 years, respectively (p=0,614). After subgroup analysis according to the presence and severity of individual heart change, the difference remained non-significant for the above-mentioned outcomes. Overall survival in Group 1 and 2 was 92% and 96% at 1 month, 61% and 86% at 1 year and 52% and 80% at 2 years, respectively (p<0,001). LVEF<40% was associated with worse overall survival (p<0,001), as was moderate to severe valvular heart disease (p=0,004). Conclusion: Our study suggests that moderate to severe heart disease, detected in TTE, does not influence limb-related outcomes after revascularization procedures. However, patients with valvular heart disease or LVEF reduction have worse overall survival. We should not expect worse limb outcomes in patients with heart disease, but aggressive tertiary prevention should be provided to improve vital prognosis.