Ruy e Fernandes

Rectus femoris muscle flap based on proximal insertion mobilization to cover a groin infected vascular graft

The rectus femoris (RF) muscle flap, which is widely used to cover groin infected vascular grafts, is usually harvested through distal tendon division and an extensive muscle elevation and transposition into the groin wound defect. A case of a vascular prosthetic graft infection in the groin was successfully controlled after coverage with an RF flap that was harvested based on proximal portion mobilization instead of the conventional distal one. This case suggests that the RF muscle flap based on proximal insertion mobilization is a feasible, effective, technically simpler, and less invasive alternative to cover infected vascular grafts in the groin.

Endovascular Repair of Bilateral Carotid Dissection in a Near Hanging Victim

Introduction There is much debate in the literature regarding the management of blunt cervical carotid injuries. This report describes a case of bilateral carotid artery dissection in the very uncommon case of a near hanging victim and the treatment controversies regarding its management. Report A 50 year old male patient was admitted after attempted suicide through hanging, having been swiftly rescued by a bystander. On admission, six hours after the event there was no neurological deficit. There was evidence of soft tissue damage related to the rope position, subcutaneous emphysema, and neck swelling. The CT angiogram showed dissection of both common carotid arteries with significant luminal narrowing as well as fracture of the thyroid cartilage; brain injury was excluded. Heparin infusion was started and an endovascular repair with bilateral covered stent placement, requiring coverage of the external carotid artery on the left side, was performed. The vascular procedure was uneventful. The patient was discharged 36 days after the event, on dual antiplatelet drugs and under regular psychiatric and speech therapy care, and is currently alive and well 22 months after surgery with no neurological damage. Discussion The choice of treatment was not straightforward as there are no guidelines or consensus around its management. In this case, however, an endovascular repair seemed suitable and the result was optimal, with no neurological damage and a good result after 22 months.

Acute acalculous cholecystitis as a rare manifestation of chronic mesenteric ischemia. A case report

Highlights • Acute acalculous cholecystitis can present de novo in an outpatient setting without any major illness or associated trauma and aortic occlusive disease may represent the most relevant etiological factor in these patients.• In the settings of chronic mesenteric ischemia, acute acalculous cholecystitis may be interpreted as a herald sign of critical ischemia and mesenteric infarction as a consequence of an acute-on-chronic mesenteric ischemia.• In our patient, the decision was taken to proceed with immediate mesenteric revascularization simultaneously with the cholecystectomy in order to minimize the risk and extension of a possible bowel infarct.

Ultrasonographic Quantification of Carotid Stenosis: A Reappraisal Using a New Gold Standard

Atherosclerotic disease involving the carotid bifurcation is a major cause of cerebrovascular events and its treatment, by endarterectomy or stenting, aims to prevent stroke and disability.

Activity Index: A Tool to Identify Active Carotid Plaques

Carotid bifurcation disease is a major cause of stroke in the western population. Atherosclerotic plaques located at the carotid bifurcation are a source of atheroembolization into the brain and may also cause flow restriction. Severity of stenosis is related with the risk of stroke as shown in multicenter studies. Nevertheless, in asymptomatic disease, the risk is lower and the number of operations needed to prevent one stroke is substantial. This led to the investigation of other factors beyond stenosis and related to the structure of the carotid lesion aiming to identify those lesions associated to increased risk (active plaques). High definition ultrasonography with computer-assisted analysis allows the objective investigation of plaque echogenicity and structure. The authors present an ultrasonographic index (Activity Index) which was shown to be accurate in the identification of symptomatic (active) carotid plaques and provided to be useful for clinical decisions.