Lisa Borges

Successful treatment of calciphylaxis by a multidisciplinary approach

A 48-year-old woman performing peritoneal dialysis for end-stage renal disease presented with a painful leg ulcer. The investigation revealed an elevated parathyroid hormone level and the histological examination of the biopsy tissue from the ulcer revealed medial calcification of the arterioles, consistent with calciphylaxis. The patient developed additional ulcers in the lower limbs and treatment with antibiotics, cinacalcet, sevelamer, sodium thiosulfate, low calcium dialysate and hyperbaric oxygen therapy was instituted. The patient had a favourable outcome and after 9 months the ulcers had healed and the parathyroid hormone level reached the normal range. Calciphylaxis is a rare and life-threatening disorder associated with a mortality of 60-80%. Its pathogenesis is not fully understood hence there is no consensus in the treatment of this pathology.

Leriche Syndrome in a Patient with Situs Inversus Totalis

Situs inversus is a rare congenital defect defined by a mirror image anatomic variation of the thoracic and abdominal organs. In this situation, abdominal aortic surgery may become particularly challenging. This is the case of a 51-year-old man, who presented with an incapacitating lower limb claudication. On his workup, a complete occlusion of the infrarenal aorta requiring surgical revascularization was found. Additionally, a situs inversus totalis was identified along with a single horseshoe kidney. The patient underwent uneventfully a surgical aortobifemoral interposition. The sole modification to the standard procedure regarded the graft limbs tunneling, which was performed in a prerenal pathway in the retroperitoneal space, thus avoiding iatrogenic injury to the anteriorly positioned iliac veins. Although challenging, conventional aortic surgery can be safely accomplished in patients with situs inversus totalis.

Sepsis-induced purpura fulminans caused by Pasteurella multocida.

A 52-year-old man was admitted with a cutaneous rash associated with septic shock and multiorganic failure, 6 days after a dog bite. He was started on empiric antibiotherapy and supportive measures. The patients condition aggravated, with need for invasive mechanical ventilation and intermittent haemodialysis, and evolution from a petechiae-like rash to purpura and gangrene, culminating in bilateral lower limb amputation. The blood cultures revealed only Pasteurella multocida, after 10 days of incubation. P multocida infection is a rare cause of soft tissue infection that subsides with oral antibiotherapy. Infections causing sepsis are rare and appear in immunocompromised patients. Purpura fulminans induced by sepsis is a rare, life-threatening disorder. This syndrome should be recognised promptly, so early treatment is instituted. We found no case reports of purpura fulminans caused by Pasteurella infections in our literature review.

Iliac artery pseudoaneurysm: a rare complication following allograft nephrectomy.

Our aim is to present a case of a common iliac artery pseudoaneurysm, which complicated an allograft nephrectomy. A 27-year-old woman presented with acute abdominal pain and a palpable pulsatile mass in the right iliac fossa, 1 year after a right pelvic allograft nephrectomy. An iliac pseudoaneurysm was suspected and confirmed on triplex ultrasound and CT angiography. The patient underwent a pseudoaneurysm resection with direct repair of the previous allograft Carrell patch suture dehiscence. The intervention and recovery were uneventful and after a follow-up of 6 months, the patient remains asymptomatic with no clinical or imaging recurrence of the pseudoaneurysm.Vascular complications following allograft nephrectomy are rare but may present significant morbidity and mortality. Endovascular exclusion is currently the preferred option for the management of pseudoaneurysms following allograft nephrectomy; however, open surgical approach remains an alternative for selected patients.

Tratamento cirúrgico de malformação digital congénita do membro superior

Resumo Introducao As malformacoes arteriovenosas (MAV) podem ter uma apresentacao clinica e evolucao imprevisiveis. Por isso, o seu tratamento e ainda um desafio entre as varias patologias vasculares. MAVs das extremidades de localizacao muito periferica podem nao ser amenizaveis por emboloterapia devido ao risco elevado de necrose. Os autores apresentam um caso clinico de uma malformacao arteriovenosa congenita do membro superior que foi abordado exclusivamente por cirurgia convencional. Caso clinico Mulher de 27 anos sem antecedentes pessoais relevantes, seguida em consulta por malformacao do 5° dedo da mao direita, com agravamento progressivo de queixas de dor, impotencia funcional, deformidade do dedo da mao e incapacidade laboral. A doente foi submetida a uma resseccao da malformacao arteriovenosa e laqueacao dos principais ramos aferentes da MAV. Apos um seguimento de 8 meses, a doente apresenta a incisao cirurgica cicatrizada, sem impotencia funcional do dedo e sem evidencia clinica de recidiva. Conclusoes O tratamento cirurgico das MAV digitais do membro superior pode ser realizado de forma curativa com conservacao do dedo, com resultados esteticos e funcionais favoraveis.

Fístula aorto-entérica secundária - a propósito de um caso clínico

Resumo Os autores apresentam um caso clinico referente a um doente com antecedentes de bypass aorto-femoral esquerdo complicado por infecao, pelo que foi submetido a ressecao parcial do mesmo e construcao de bypass femoro-femoral, com necessidade de transversostomia subsequente por fistulizacao entre o colon descendente, a loca da protese removida e a parede abdominal. Apos episodios de hemorragia gastrointestinal associados a investigacao inconclusiva, a ultima TC abdominopelvica levantou suspeita de fistula aorto-enterica secundaria e o doente foi submetido a laparotomia exploradora, laqueacao da aorta abdominal e bypass axilo-“cross over” femoro-femoral. Segue-se uma revisao literaria das fistulas aorto-entericas.

Método combinado de embolização da artéria esplénica e esplenectomia laparoscópica: caso clínico

Resumo Os autores apresentam um caso clinico de uma mulher, de 53 anos, com sindrome mielodisplasica, manifestada por trombocitopenia sintomatica dependente de corticoterapia em doses elevadas. A doente foi referenciada a consulta de Cirurgia Vascular, pela Hematologia, para ponderacao de embolizacao da arteria esplenica. A doente foi submetida a embolizacao total da arteria esplenica por coils e esplenectomia laparoscopica no dia seguinte. Os dois procedimentos foram bem sucedidos e decorreram sem complicacoes. A doente teve alta ao quarto dia pos-operatorio, assintomatica, clinicamente estavel e com hemograma que revelava 208 000 plaquetas/μL. O metodo combinado de embolizacao da arteria esplenica e esplenectomia laparoscopica e um procedimento seguro e eficaz, associado a diminuicao de incidencia de complicacoes e de tempo de internamento, quando comparado a esplenectomia laparoscopica isolada.