Abstract Introduction: Treatment decision in patients with asymptomatic carotid artery stenosis (ACS) is a matter of current debate with a recent shift towards isolated best medical treatment (BMT) as treatment of choice in most patients. However, poor medical compliance is one of the main constraints to the success of BMT. We hypothesized that more invasive treatment approaches can influence how patients perceive the severity of their illness and hence, treatment compliance. Methods: A cross-sectional study was performed including patients with asymptomatic >50% carotid artery stenosis (NASCET method) followed-up as outpatients in a Vascular Surgery department from January 2017 to December 2021. Optimal BMT was defined according to the European Society of Vascular Surgery Carotid Atherosclerotic Disease 2023 guidelines. Demographic and risk factor patient data was attained and subsequently a Portuguese translation of the Morisky medication-taking adherence scale (MMAS-4) questionnaire was given to all patients. Several additional questions developed by our group were also applied. Results: A total of 320 patients were identified (186 under BMT alone and 134 submitted to BMT and carotid endarterectomy - CEA). Most patients were male in both groups (75%) and the mean age was similar. Furthermore, patients undergoing CEA presented higher rates of current smoking (51.4% vs 15.9%; p<0.001) and lower rates of antiplatelet (80.0% vs. 92.8%; p=0.029) and statin (78.6% vs. 94.2%; p=0.007) prescription. Patients in the CEA group also presented with significantly lower medical compliance (40.3% vs. 24.5%, p<0.001) despite being more aware of their current medication´s name and therapeutic purpose. Conclusion: In conclusion, physicians seem to be more aggressive in controlling risk factors in BMT-only patients when compared to CEA-submitted patients. However, patients subjected to CEA may be more aware of ACS, despite having poorer medical adherence.

Abstract Background: Endovascular mechanical thrombectomy (MT) changed acute ischaemic stroke management and is considered the standard of care for patients with proximal anterior circulation occlusion. MT improves functional independence, without an increase in mortality. Despite its advantages, up to 20% of patients treated with MT do not have successful recanalization, leading to poor clinical outcome. We present a case of an acute ischaemic stroke of the anterior circulation due to occlusion of the common carotid artery successfully submitted to surgical thrombectomy after failed MT. Case report: A 43-year-old male, with prior history of diabetes, hypertension, dyslipidaemia and heart failure was admitted at the emergency unit with acute bilateral lower limb ischaemia, due to cardioembolic phenomena. He was submitted to bilateral femoral thrombectomy and started endovenous unfractionated heparin. On the fifth postoperative day he developed sudden depression of cognitive status and left side hemiplegia of brachial predominance. Computed tomography angiography revealed an occlusion of brachiocephalic trunk, right subclavian artery and common carotid artery, preserving its branches. MT, performed by interventional neuroradiology, was unsuccessful (no recanalization or clinical improvement). After multidisciplinary discussion, the patient underwent urgent surgical thrombectomy through carotid and transaxillary approaches. Postoperatively, the patient’s mental status and left sided motor function recovered progressively over time. Three months after, patient maintains anticoagulation with warfarin, without neurological sequalae. Conclusion: The low rate of recanalization and poor clinical outcome after MT failure underlines the need for alternative rescue approaches. Surgical thrombectomy could represent a lifeline. More studies are needed to corroborate its efficacy in patients with anterior circulation acute ischaemic stroke.

Resumo A doença quística adventicial é uma patologia que afeta principalmente o leito arterial, porém, em raros casos pode envolver o sistema venoso. O objetivo desta revisão foi padronizar a marcha diagnóstica, tratamento e vigilância de doentes com suspeita de doença quística adventicial venosa. Para cumprir os objetivos supracitados, uma revisão narrativa sumarizando os principais achados da literatura usando as bases de dados PUBMED e EMBASE foi feita. Um total de 33 artigos foram selecionados traduzindo-se num total de 41 casos de vACD. Após analise dos dados, foi possível concluir que o vaso mais frequentemente atingido é a veia femoral comum, e a maior parte dos doentes refere edema unilateral de membro com tempo de evolução variável. Quando perante um doente com edema unilateral de membro, em que a TVP foi excluída, é necessário proceder a outros meios complementares de diagnóstico de forma a confirmar, ou excluir, a vACD.

Abstract Introduction: The development of a uretero-arterial fistula (UAF) is a rare and life-threatening condition. Owing to its low prevalence, diagnosis and management remains a challenge for both urologists and vascular surgeons and UAF’s high mortality rates may be at least partially attributed to delayed diagnosis. We present a case of UAF in a patient with previous pelvic surgery and indwelling ureter catheter. Case report: An 82-year-old male presented to the emergency department with haemodynamic instability and gross haematuria that started one hour prior to admission. The laboratory study performed showed an acute anaemia of 7.5g/dl and a contrast enhanced computed tomography revealed a ureteral fistula between the stented left ureter and the common iliac artery. The patient was taken to the angiography suit and a balloon-expandable stent-graft (GORE® VIABAHN® VBX - 11mm diameter and 59mm in length) was deployed. Following the procedure, the haematuria resolved, and the patient had an uneventful post-operative stay. He was discharged two weeks after admission, following a course of large spectrum antibiotic therapy. The patient remained asymptomatic at 3 month follow up. Conclusions: Uretero-arterial fistula is an uncommon condition but with an increasing prevalence, at least in part due to improved pelvic cancer treatment.

Resumo A doença quística adventicial é uma patologia que afeta principalmente o leito arterial, porém, em raros casos pode envolver o sistema venoso. O objetivo desta revisão foi padronizar a marcha diagnóstica, tratamento e vigilância de doentes com suspeita de doença quística adventicial venosa. Para cumprir os objetivos supracitados, uma revisão narrativa sumarizando os principais achados da literatura usando as bases de dados PUBMED e EMBASE foi feita. Um total de 33 artigos foram selecionados traduzindo-se num total de 41 casos de vACD. Após analise dos dados, foi possível concluir que o vaso mais frequentemente atingido é a veia femoral comum, e a maior parte dos doentes refere edema unilateral de membro com tempo de evolução variável. Quando perante um doente com edema unilateral de membro, em que a TVP foi excluída, é necessário proceder a outros meios complementares de diagnóstico de forma a confirmar, ou excluir, a vACD.

Abstract Introduction: The development of a uretero-arterial fistula (UAF) is a rare and life-threatening condition. Owing to its low prevalence, diagnosis and management remains a challenge for both urologists and vascular surgeons and UAF’s high mortality rates may be at least partially attributed to delayed diagnosis. We present a case of UAF in a patient with previous pelvic surgery and indwelling ureter catheter. Case report: An 82-year-old male presented to the emergency department with haemodynamic instability and gross haematuria that started one hour prior to admission. The laboratory study performed showed an acute anaemia of 7.5g/dl and a contrast enhanced computed tomography revealed a ureteral fistula between the stented left ureter and the common iliac artery. The patient was taken to the angiography suit and a balloon-expandable stent-graft (GORE® VIABAHN® VBX - 11mm diameter and 59mm in length) was deployed. Following the procedure, the haematuria resolved, and the patient had an uneventful post-operative stay. He was discharged two weeks after admission, following a course of large spectrum antibiotic therapy. The patient remained asymptomatic at 3 month follow up. Conclusions: Uretero-arterial fistula is an uncommon condition but with an increasing prevalence, at least in part due to improved pelvic cancer treatment.

Abstract Introduction: Aortoiliac occlusive disease (AIOD) can be treated using either open surgical revascularization (OSR) or endovascular revascularization (ER). Methods: A Medline search was performed in order to identify articles focused on the treatment of aortoiliac occlusive disease. Additional articles of scientific interest for the purpose of this non-systematic review were included by cross-referencing. Results: There are a few articles reporting direct results between both techniques based on retrospective or prospective single center or multicenter studies. In the majority of studies, primary patency is generally better for surgery in comparison to ER, but at a cost of more postoperative complications, with higher rates of respiratory failure and wound infection in the open group. On the other hand, endovascular recanalization is related to higher rates of limb ischemia/thrombosis, renal dysfunction and reinterventions. In the presence of femoral artery calcified disease, the hybrid approach should be considered. Conclusions: Endovascular treatment is a suitable alternative for extensive AIOD and can be accomplished in a less invasive manner, with most midterm outcomes comparable with open reconstruction. Surgery should be reserved for multilevel calcified disease and after endovascular failure.

Abstract Objective: Venous stenting of iliocaval obstructions has become a more frequent procedure over the last two decades. In-stent stenosis and thrombosis are potential complications, causing one of the main causes of symptoms recurrence and impacting quality of life. The aim of this review is to report on the impact of venous stent patency loss, as well on risk factors and management. Methods: A systematic review was conducted according to the recommendations of the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. Results: After a literature search, 12 studies (two prospective and 10 retrospective studies) were included in the analysis. A total of 1981 patients (34.1% male) and 2388 limbs (63.6% left side) were assessed. Mean age was 43.5 years (range 16-99). Indication for stenting included deep venous thrombosis (DVT) (4%), post-thrombotic syndrome (PTS) (18.8%) and non-thrombotic iliac vein lesions (NIVLs) (77.2%). Regarding treatment, most patients were submitted to angioplasty and stenting only (87%). Associated catheter directed thrombolysis or mechanical thrombectomy was performed when indicated (8.4%), and in the remaining an AVF/endophlebetomy was performed (4.6%). Primary, primary assisted and secondary patency rates at one year ranged from 68-100%, 79-90% and 85.8-100%, respectively. Reported anticoagulation duration after stenting ranged from 1-12 months. In one study involving only patients treated for NIVLs, no anticoagulation was prescribed, and antithrombotic therapy was continued for three months. Follow-up strategies included clinical and imagiological control with a mean follow-up of 19.7 months. Post-procedural stent re-stenosis was reported in 121 limbs (5.1%) and stent occlusion in 81 limbs (3.4%); the latter was distributed as follows: 11.1% after DVT, 77.8% PTS and 11.1% NIVLs. A total of 186 re-interventions were performed in symptomatic patients. The prognostic factor most consistently associated with stent failure was thrombotic inflow veins. Other reported factors were incomplete thrombolysis and age younger than 40 years. Stent placement below the inguinal ligament, type of stent and anticoagulation regimen do not seem to affect stent patency. Conclusion: Regarding venous lesions of the lower limbs, a selective approach and planning should focus on identification of risk factors for stent failure. It is noteworthy that most stent occlusions occur in post-thrombotic limbs. Stent failure continued after 6 months, emphasizing the importance of an extended surveillance especially on these patients.

Abstract This article seeks to provide a significant overview of the impact of globalization upon the international system, exploring its main dimensions, dilemmas and political consequences. The principal conclusion suggests the need for a new generation of international institutions.

Resumo Este artigo pretende encetar uma visão abrangente do impacto da globalização sobre o sistema internacional, explorando as suas principais dimensões, dilemas e consequências políticas. A conclusão central aponta para a necessidade de estruturar uma nova geração de instituições internacionais.

Resumo Introdução: A agenesia da veia cava inferior é uma das anomalias mais raras deste vaso, com uma prevalência estimada de 0,0005-1% na população geral. Porém, cerca de 5% dos pacientes com menos de 30 anos com uma trombose venosa profunda apresentam esta anomalia. Métodos e material: Relato de dois casos clínicos de agenesia da veia cava inferior com diferentes apresentações clínicas. Caso clínico 1: Um homem de 40 anos recorreu à urgência com queixas de edema e dor no membro inferior esquerdo, progredindo gradualmente para incapacidade de marcha. Ao exame físico foi encontrado edema e dor a palpação da perna e coxa, bem como veias colaterais abdominais superficiais proeminentes. O ecodoppler venoso mostrou trombose venosa profunda esquerda estendendo-se da veia poplítea até a veia ilíaca comum. O angio-TC mostrou agenesia da veia cava infrarrenal e veias renais a drenar para os sistemas ázigos e hemiázigos. O paciente teve alta com rivaroxabano e meias elásticas. Aos 2 meses mantinha-se hipocoagulado e estava assintomático. Caso clínico 2: Uma mulher de 35 anos, com história prévia de cirurgia de varizes de membros inferiores recorrentes e úlcera do maléolo interno esquerdo, apresentou-se na consulta com recorrência da úlcera. O angio-TC revelou ausência de veia cava infra-hepática, veias ázigos e hemiázigos dilatadas com colaterais retroperitoneais dilatadas. A paciente iniciou cuidados de penso com óxido de zinco e rivaroxabano oral. Discussão/conclusão: A maioria dos pacientes com agenesia da veia cava inferior permanece assintomática. No entanto, quando sintomática, a maioria apresenta-se com uma trombose venosa profunda proximal envolvendo as veias ilíaca e femoral. A TC ou RM devem ser os métodos imagiológicos usados para diagnosticar esta anomalia. Nenhum consenso claro foi alcançado sobre a estratégia terapêutica, além da anticoagulação de longo prazo e uso de meias elásticas.

Abstract Introduction: Inferior vena cava agenesis is one of the most uncommon anomalies of this vessel, with an estimated prevalence of 0.0005-1% in the general population. However, around 5% of the patients younger than 30 years with a diagnosis of deep vein thrombosis have this anomaly. Methods and material: Report of two clinical cases of inferior vena cava agenesis with different clinical presentations. Clinical case 1: A 40-year-old man was admitted with a 3 days history of unilateral lower limb swelling and pain, gradually progressing to the inability to walk. On physical examination he had swelling, bruising and tenderness involving leg and thigh and prominent engorged superficial abdominal collateral veins. Venous Doppler Ultrasound showed left deep venous thrombosis extending from popliteal vein to common iliac vein. A computed tomography angiogram showed agenesis of the infrarenal vena cava and patent renal veins draining in to the azygous system and hemiazygous systems. The patient as discharged with rivaroxaban and compression stockings. At 2 months follow up he was asymptomatic and still anticoagulated. Clinical case 2: A 35 year- old woman, with a previous history of recurrent lower limb varicose veins surgery and left internal malleolar ulcer at 30 years presented at medical department 3 years later with complains of ulcer recurrence. A computed tomography angiogram revealed an absent infrahepatic vena cava, prominently dilated azygos and hemiazygos veins with enlarged retroperitoneal collaterals. The patient initiated dressing care with oxide zinc and oral rivaroxaban. Discussion/conclusion: The majority of cases remain asymptomatic. However, when symptomatic, the majority present as proximal DVT involving the iliac and femoral veins. CT or MRI should be the imagiological methods used to diagnose this anomaly. No clear consensus has been reached on therapeutic strategy, other than long-term anticoagulation and elastic stockings.

Resumo Fundamento: Enquanto a angiografia coronária invasiva é considerada padrão outro para o diagnóstico da doença arterial coronariana (DAC), envolvendo os vasos coronários epicárdicos, a revascularização coronariana guiada por fisiologia representa uma prática padrão ouro contemporânea para a administração invasiva de pacientes com DAC intermediária. Porém, os resultados de longo prazo da avaliação da gravidade da estenose por meio da fisiologia, em comparação à angiografia como guia para a cirurgia de bypass – enxerto de bypass de artéria coronária (CABG), ainda são incertos. Esta metanálise visa avaliar os resultados clínicos de um CABG guiado por fisiologia em comparação a um CABG guiado pela angiografia. Objetivos: Buscamos determinar se os resultados entre um CABG guiado por fisiologia e os de um CABG guiado por angiografia são diferentes entre si. Métodos: Pesquisamos nas bases Medline, EMBASE e Cochrane Library. A última data de busca foi junho de 2020, e todos os estudos anteriores foram incluídos. Realizamos uma metanálise de razão de risco agrupado para quatro principais resultados: morte por todas as causas, infarto do miocárdio (IM), revascularização do vaso alvo (TVR) e eventos cardiovasculares adversos maiores (MACE). Valor de p <0,05 foi considerado estatisticamente significante. A heterogeneidade foi avaliada com o teste Q de Cochran, e quantificada pelo índice I2. Resultados: Identificamos cinco estudos incluindo um total de 1.114 pacientes. Uma metanálise agrupada não demonstrou diferenças significativas entre a estratégia da fisiologia e da angiografia para IM (razão de risco [RR] = 0,72; IC95%, 0,39–1,33; I2 = 0%; p = 0,65), TVR (RR = 1,25; IC95% = 0,73–2,13; I2 = 0%; p = 0,52), ou MACE (RR = 0,81; IC95% = 0,62–1,07; I2 = 0%; p = 1). A estratégia da fisiologia apresentou 0,63 vezes o risco de morte por todas as causas em comparação à estratégia da angiografia (RR = 0,63; IC95% = 0,42–0,96; I2 = 0%; p = 0,55). Conclusão: Esta metanálise demonstrou uma redução nas mortes por todas as causas quando usada a estratégia do CABG guiado por fisiologia. Porém, o curto período de acompanhamento, o tamanho da amostra pequeno dos estudos incluídos e a não-discriminação das causas de morte podem justificar essas conclusões. Estudos com períodos mais longos de acompanhamento são necessários para tirar conclusões mais robustas e definitivas.

Abstract Background: While invasive coronary angiography is considered the gold standard for the diagnosis of coronary artery disease (CAD) involving the epicardial coronary vessels, coronary physiology-guided revascularization represents a contemporary gold-standard practice for the invasive management of patients with intermediate CAD. Nevertheless, the long-term results of assessing the severity of stenosis through physiology compared to the angiogram as the guide to bypass surgery – coronary artery bypass grafting (CABG) are still uncertain. This meta-analysis aims to assess the clinical outcomes of a physiology guided CABG compared to the angiography-guided CABG. Objectives: We sought to determine if outcomes differ between a physiology guided CABG compared to an angiography-guided CABG. Methods: We searched Medline, EMBASE, and the Cochrane Library. The last date for this search was June 2020, and all of the previous studies were included. We conducted a pooled risk-ratio meta-analysis for four main outcomes: all-cause death, myocardial infarction (MI), target vessel revascularization (TVR) and major adverse cardiovascular events (MACE). P-value <0.05 was considered as statistically significant. Heterogeneity was assessed with Cochran's Q test and quantified by the I2 index. Results: We identified five studies that included a total of 1,114 patients. A pooled meta-analysis showed no significant difference between a physiology guided strategy and an angiography-guided strategy in MI (risk ratio [RR] = 0.72; 95%CI, 0.39–1.33; I2 = 0%; p = 0.65), TVR (RR = 1.25; 95%CI = 0.73–2.13; I2 = 0%; p = 0.52), or MACE (RR = 0.81; 95%CI = 0.62–1.07; I2 = 0%; p = 1). The physiology guided strategy has 0.63 times the risk of all-cause death compared to the angiography-guided strategy (RR = 0.63; 95%CI = 0.42–0.96; I2 = 0%; p = 0.55). Conclusion: This meta-analysis demonstrated a reduction in all-cause death when a physiology guided CABG strategy was used. Nevertheless, the short follow-up period, small sample size of the included studies and the non-discrimination of the causes of death can largely justify these conclusions. Studies with an extended follow-up period of observation are required to draw more robust and definitive conclusions.

Resumo O presente artigo explora a construção de uma problemática racional sobre a crescente expansão da China, revisitando as questões conexas dos ciclos longos, das transições hegemónicas e da chamada «armadilha de Tucídides», entre outras dimensões de análise, na base de alguns dos mais importantes delineamentos teóricos de Tucídides, Kautilya, Organski, Modelski, Gilpin e G. Allison. A conclusão aponta para a ideia de que o atual sistema internacional revela já uma nova era de contenção estratégica.

Abstract This article attempts to build a rational case about China’s burgeoning expansion revisiting the interrelated questions of the long cycles, hegemonic transitions and the so-called “Thucydides’s trap” among other analytical dimensions, drawing mainly upon some of the most important theoretical propositions from Thucydides, Kautilya, Organski, Modelski, Gilpin, and G. Allison. The conclusion points to the idea that the current international system already reveals a new phase of strategic containment.

Resumo Introdução: A lesão traumática da artéria poplítea, apesar de ser uma entidade clínica rara é a causa mais comum de amputação associada a trauma dos membros inferiores. O objetivo deste estudo foi descrever a incidência de lesão artéria poplítea após trauma do joelho e descrever a abordagem terapêutica e seus resultados. Métodos e materiais: Os códigos CID-10 / CID-9 (S85.0 / 904.41; S83.1 / 836.5; S83.4; S83.5; S72,4 / 821.2; S82,1 / 823.0) foram usados para identificar os pacientes admitidos no nosso centro terciário no período de 01/01/2010 a 31/5/2021 com o diagnóstico de lesão artéria poplítea e/ou trauma do joelho. Foi posteriormente realizada uma análise estatística destes pacientes através do programa SPSS versão 27. Resultados: No nosso centro no período de 1/1/2010 a 31/5/2021 foram admitidos 535 doentes com trauma do joelho (28 com luxação do joelho e 507 com fratura próxima ao joelho) e 9 doentes com lesão da artéria poplítea (7 homens, com idade mediana de 39,0 anos). Os mecanismos de lesão da artéria poplítea foram acidentes de mota (4) ou de bicicleta (1) ; um acidente de trabalho com maquinaria pesada, uma queda, um atropelamento e uma lesão iatrogénica. A incidência de lesão da artéria poplítea após trauma do joelho foi de 1.5% - após luxação do joelho foi de 17.9% e após fratura do joelho foi de 0.8%. Relativamente a lesões associadas, quatro doentes tinham lesões extensas de tecidos moles, dois tinham lesão venosa e dois tinham lesão nervosa. O tempo mediano de isquemia foi de 6.0 horas e o tempo médio de intervenção vascular de 2.4 horas. Em relação ao tratamento vascular realizado, oito doentes foram submetidos a cirurgia de revascularização por bypass e um foi tratado conservadoramente. Em três doentes foram realizadas fasciotomias terapêuticas. Não foi realizada nenhuma amputação primária e foi realizada uma amputação secundária. O tempo médio de internamento hospitalar foi de 24.9 dias e a mortalidade foi de 0%. Durante o follow-up, apenas três pacientes voltaram ao seu nível de atividade normal e seis ficaram com limitações na realização das atividades de vida diária. Discussão/Conclusão: O risco de lesão da artéria poplítea após luxação do joelho é maior do que após fratura do joelho (17,9% vs 0,8% no nosso estudo e 3,4-8,2% vs 0,2% no registo sueco) e, portanto, os ortopedistas devem estar conscientes deste risco aumentado de lesão vascular. A taxa de amputação na nossa série foi menor do que a do registo Sueco e a do Banco de Dados Nacional de Trauma dos Estados Unidos (11% vs 28% vs 14,5%, respetivamente). No entanto, 11% é ainda assim uma taxa elevada, uma vez que afeta principalmente uma população jovem e ativa e apenas 33.3% dos pacientes regressaram a uma vida normal. Assim sendo, uma abordagem multidisciplinar é essencial para diminuir o tempo de isquemia e promover um tratamento holístico do doente.

Abstract Introduction: Traumatic popliteal artery injury is a rare clinical entity, but it is the most common cause of amputation in injured extremities. The aim of this study was to report the incidence of popliteal artery injury after knee trauma and report therapeutic management and results. Methods and material: ICD-10/ ICD-9 codes (S85.0/904.41; S83.1/836.5; S83.4; S83.5; S72,4/821.2; S82,1/823.0) were used to identify patients admitted with popliteal artery injury and/or knee trauma at our tertiary center from 1/1/2010 to 31/5/2021. A statistical analysis was realized using the SPSS program version27. Results: At our center from 1/1/2010 to 31/5/2021 535 patients were admitted due to knee trauma (28 with knee dislocation and 507 with fracture close to the knee) and 9 patients with popliteal artery injury (seven males, median age 39.0 years) The mechanism of PAI was motorcycle (4) or bicycle (1) or work (1) accidents (4); one fall, one running over and one iatrogenic injury. The incidence of PAI after knee trauma was 1.5%, after knee dislocation 17.9% and 0.8% after fracture close to the knee. Regarding associated injuries, four patients had severe soft tissue damage, two had venous injuries and two had nerve disruptions. The median ischemic time was 6.0 hours and mean vascular surgical time was 2.4 hours. Regarding vascular treatment, eight patients were submitted to bypass surgery and one was treated conservatively. Therapeutic fasciotomies were performed in three patients. No primary amputations were performed. A secondary major amputation was performed in one patient. The mean hospital length of stay was 24.9 days and mortality was 0%. Three patients returned to their normal activity level and six were limited in their daily activity. Discussion/Conclusion: The risk of PAI after knee dislocation is higher than after knee fracture (17,9% vs 0.8% in our study, and 3,4-8,2% vs 0,2 % in Swedish registration), so orthopedic surgeons must be aware of that increased risk, to avoid missing this diagnosis. The amputation rate in our serie was lesser than the Swedish registration and the United States National Trauma Data Bank (11% vs 28% and 14,5%, respectively). However, it´s still a high rate considering that it mostly affects a young and active population and only 33.3% patients return to a normal life. A multidisciplinary approach is essential to decrease ischemia time and to promote a holistic treatment.