Daniel Brandão

Duodenocaval fistula as a result of a fish bone perforation.

Duodenocaval fistula is a rare and potentially lethal condition. We report a case of a 61-year-old female with a duodenocaval fistula resulting from a fish bone perforation of the duodenum who survived with conservative treatment. To our knowledge, this is the first reported case of a duodenocaval fistula caused by a fish bone. Additionally, besides revising the other possible etiologies for duodenocaval fistulae, we also discuss its diagnosis and treatment.

Upper limb ischemia in a patient with Wegener's granulomatosis.

OBJECTIVES We report a clinical case of a small-vessel vasculitis with ischemia of the left upper limb. CASE A patient diagnosed with Wegeners granulomatosis and involvement of the left axillary and brachial arteries. A left axillary-radial bypass with reversed left great saphenous vein was performed. RESULTS After a period of 36 months of follow-up the patient is asymptomatic with complete healing of the trophic lesions. CONCLUSION Classic Wegeners granulomatosis is a form of vasculitis that primarily involves the upper and/or lower respiratory tract and kidney. The amount of clinical symptoms is enormous and the diagnosis, arduous. In the literature there are only a few clinical cases referring to limb ischemia in a setting of Wegeners granulomatosis. This is a unique case report of upper limb ischemia due to involvement of a medium-large size artery in a patient with Wegeners granulomatosis.

Cost-effectiveness of the endovascular repair of abdominal aortic aneurysm in Portugal

Endovascular Aneurysm Repair (EVAR) for the treatment of aortic abdominal aneurism has been shown to improve short-term survival and quality of life as compared to Open Repair (OR), while reducing the rate of serious complications and allowing for the treatment of more patients. Objectives: To examine the cost-effectiveness of EVAR compared to OR in the treatment of aortic abdominal aneurism in the Portuguese context using a model previously developed in the UK. Methodology: We adapted an international economic evaluation model to the Portuguese situation, assuming that the health benefits of EVAR observed in clinical trials would also apply to Portuguese patients. We carried out an expert panel survey to calculate the resource use associated with the intervention and its short and long-term consequences, valued with Portuguese prices. Results: The major cost difference in the primary intervention (difference of 3,064 € in favor of OR) is related to the cost of the endograft/graft. No major differences are observed in the total cost of complications and re-interventions between the two procedures. EVAR represents a cost of 16,709 € over lifetime compared to 12,130 € for OR. Using data from the literature

Técnica de reversão de extensão ilíaca cónica de endoprótese: caso clínico

Resumo O tratamento de aneurismas iliacos configura um desafio terapeutico. A cirurgia convencional associa-se a taxas de morbi-mortalidade elevadas, o que conduziu ao desenvolvimento de alternativas menos invasivas, tais como tecnicas endovasculares. No tratamento endovascular de um aneurisma da arteria iliaca comum (AIC) e fundamental garantir boas landing zones , o que pode obrigar a estender a landing zone distal a arteria iliaca externa (AIE), geralmente menor que a AIC. Para colmatar esta diferenca de diâmetros entre as landing zones proximal e distal foi descrita a tecnica off-label de reversao de extensao iliaca conica de endoprotese. Os autores descrevem um caso clinico de tratamento endovascular bem sucedido de aneurisma AIC, aplicando esta tecnica.

Síndrome da veia cava superior: caso clínico

Resumo A Sindrome da Veia Cava Superior (SVCS) surge quando ha diminuicao ou obstrucao do fluxo de sangue atraves da veia cava superior (VCS) e pode cursar com manifestacoes clinicas muito debilitantes. Embora classicamente associada a etiologias malignas, o aumento do numero de procedimentos endovenosos (cateteres venosos centrais, pacemakers, cardio-desfibriladores) fez aumentar a percentagem de casos de etiologia benigna, que actualmente correspondem a 40%. O tratamento endovascular tem ganho crescente popularidade, mas nem sempre e exequivel ou conduz a melhoria clinica a longo prazo, pelo que por vezes o tratamento cirurgico e necessario. Os autores descrevem o caso clinico de um doente com SVCS, relacionado com colacacao previa de pacemaker. Apos tentativa infrutifera de tratamento endovascular, o doente foi submetido a reconstrucao cirurgica, com resolucao da sintomatologia.

Recurrent carotid in-stent restenosis treated with a Paclitaxel-Eluting Balloon: case report and review of literature

Abstract Introduction Carotid artery stenting (CAS) is a valid alternative to carotid endarterectomy with proper indications. In-stent restenosis (ISR) is a possible complication and there are multiple therapeutic options for severe ISR (>70%). The use of drug-eluting balloons (DEB) has increasing evidence as a new endovascular treatment for ISR. The authors report a case of recurrent ISR treated with a DEB. Case report Male patient, 67 years-old, with a history of cervical radiation in 2006. In 2007, he had a stroke in the territory of the right internal carotid artery (ICA). The duplex ultrasound (DUS) showed right ICA occlusion and left ICA stenosis >70%. He underwent left CAS under filter protection, without complications. He was kept as an outpatient and in 2009 he presented ISR >70%. The patient was treated with re-stenting, without residual stenosis and had an uneventful course. In 2012, DUS revealed recurrent ISR >70%. Angioplasty with a paclitaxel-eluting balloon was performed, with distal cerebral protection, good imaging and hemodynamic results and an uneventful course. At 6 months of follow-up, the patient has no complications and no ISR documented by ultrasound. Conclusions The use of DEB in the treatment of ISR after CAS is an emerging strategy with promising results.

Below the Knee Techniques: Now and Then

Critical Limb Ischemia (CLI) is defined as the presence of ischemic rest pain for more than two weeks or ischemic tissue loss associated with an absolute ankle pressure less than 50 mmHg or great toe pressure less than 30 mmHg (Norgren et al., 2007). Patients with CLI experience high amputation rates, significant morbidity and cardiovascular events exceeding those in patients with symptomatic coronary heart disease (Varu et al., 2010). In spite of recent developments in revascularization techniques and wound care centers, amputations continue to be performed, partly because patients with CLI are referred late to vascular surgeons (Varu et al., 2010). However, revascularization when compared with amputation have an overall lower perioperative mortality and enhanced long-term survival (Brosi et al., 2007; Varu et al., 2010). However, CLI is associated with multisegmental complex arterial lesions and consequently with high rates of revascularization failure (Allie et al., 2009). Specific features of the tibial vessels, such as the small caliber, the remote location, the slow flow of the distal bed, and the need of preserving runoff capacity, make this vascular territory particularly challenging for endovascular treatment (Blevins and Schneider, 2010). Meanwhile, continued technical improvements and very encouraging results have changed the paradigm of CLI therapy, until recently based on vein graft bypass. As so, the endovascular approach is, nowadays, the first-line modality for limb-threatening ischemia for a majority of authors (Allie et al., 2009; DeRubertis et al., 2007).