[Varicose veins of lower limbs: progress in the surgical management]

Varicose veins are part of the spectrum of Chronic Venous Disease. They are very prevalent, especially among women and involve mainly the great saphenous vein.Pathogenesis of varicose veins is complex and multifactorial. There is a valvular incompetence as well as a dilation in the vein wall. However, the sequence in which these mechanisms occur is unknown. Probably the valves become incompetent secondary to vein wall abnormalities.The first description of the surgical technique used today came in the transition from the nineteenth to the twentieth century. In the last decade, the great debate evolved around the new techniques of endovascular radiofrequency and laser ablation. These follow the global trend of Medicine to use less invasive techniques.This study, besides performing a contextualization and review of concepts about varicose veins, especially intends to launch the latest data on the state-of-the-art regarding the treatment of this disease, and stands on data collected from Pubmed.It gets clear that endovascular techniques are safe and effective, besides revealing better results in terms of postoperative morbidity when compared with classic surgery. However, the last decade was marked by constant improvements in techniques, creating difficulties in interpreting data presented in trials. Furthermore, there is progressively greater difficulty in randomizing patients, given their preference for less invasive procedures over traditional surgery. New trials on the long-term efficacy in addition to detailed analysis of costs will also be crucial for the implementation of these new methods.

The need for reintervention is not higher after EVAR: an eight years single center experience

OBJECTIVE

To evaluate and compare the effectiveness and clinical outcomes of abdominal aortic aneurysm treatments.

METHODS

The medical records of all patients who underwent elective open or endovascular repair of nonruptured infra-renal abdominal aortic aneurysm from January 2001 to April 2009 were retrospectively reviewed. The assessed outcomes were all-cause mortality, aneurysm-related mortality, incidence of perioperative complications and reinterventions. Patient demographics and procedure characteristics were also analysed.

RESULTS

One hundred and eighty four consecutive patients were included: 107 ( 58 % ) had open surgery and 77 ( 42 % ) had endovascular repair ( EVAR ). Medical complications were more frequent after open surgery ( 24 % vs 10 %; p=0.025 ). There was no perioperative mortality in the EVAR group, whereas in open surgery 9 deaths occurred ( 8.4 % in-hospital mortality; p=0.011 ). At 7 years, all cause mortality was similar in the two groups ( 27 vs 30 %; p=0.34 ). There was, however, a persistent difference in aneurysm-related mortality ( Kaplan-Meier estimates were 9.5 % in the open repair group and 1.5 % in the EVAR group; p=0.023 ). Reintervention rates for EVAR were not higher than those for open surgery ( at 5 years, 21.2 % vs 21.4 %; p=0.70 ).

CONCLUSIONS

In our institution, EVAR is associated with lower early mortality and morbidity compared to open repair. Despite equivalent late overall survival, endoluminal repair offers an aneurysm-related mortality 6 times inferior to open repair. The need for reintervention was similar after EVAR or open surgery. In this study setting, our findings support endovascular management of large AAAs, even in patients fit for open repair.

[Origins and development of the Vascular Surgery Department of Hospital de São João]

The authors report the history of the Vascular Surgery Department of Hospital de São João since its origin to the actual reality, mentioning the most relevant steps of its foundation, development and major contributors.

[Hybrid treatment of an aortic arch aneurysm]

Traditional open repair of aortic arch aneurysms is a complex and demanding surgery that requires cardiopulmonary bypass, hypothermia and circulatory arrest, being associated with considerable morbidity and mortality. Even with significant advances in pre-operative assessment and optimization, advanced anaesthetic techniques and intensive care, conventional aortic arch repairs remain amongst the highest risk of across all surgical specialties. Therefore, a hybrid approach with sequential transposition of the supra-aortic branches and endovascular stent-graft placement is a less invasive alternative treatment that opens the indication for repair to more critical patients. We report our institution's first experience in the hybrid surgery of aortic arch aneurysms.

[Supra-aortic trunks occlusive disease: three different treatment approaches]

Unlike carotid bifurcation atherosclerotic stenosis, supra-aortic trunks (SAT) occlusive disease is rare and its revascularization uncommon, accouting for less than 10% of the operations performed on the extracranial brain-irrigating arteries. There are three different treatment approaches: transthoracic, extra-anatomic cervical and endovascular. Endovascular repair is gaining popularity as first-line therapy for proximal lesions with favorable anatomy because of its low morbidity and rare mortality. Extra-anatomic bypass is a safe and durable reconstruction and should be considered in patients with single vessel disease, with cardiopulmonary high-risk or with limited life expectancy. If cardiac surgery is needed, central transthoracic reconstruction is preferable, and the two procedures should be combined. The long-term patency of bypasses with aortic origin, specially when multiple vessels are involved, is superior to other repair techniques. We present three clinical cases that illustrate each of these therapeutic strategies: central brachiocephalic revascularization and synchronous cardiac surgery in a patient with complex SAT atherosclerosis disease; subclavian-carotid transposition for disabling upper limb claudication; and subclavian artery stenting for subclavian-steal syndrome. Surgical approach selection should be based on the individual patient's anatomy and operative risk.

[Renal cell carcinoma extending into the right atrium. Case report]

We report the clinical case of a 48-year-old woman with advanced renal cell carcinoma, and an inferior vena cava thrombus extending into the right atrium. The patient underwent complete tumor excision with radical nephrectomy and inferior vena cava trombectomy using adjunctive cardiopulmonary bypass and deep hypothermic circulatory arrest. Pathological studies revealed no capsular invasion by the renal cell carcinoma. Eighteen months postoperatively the patient is asymptomatic and on immunosuppressive therapy for suspected metastatic disease. We discuss the morbilidity, mortality and long term survival of patients with similar presentation of renal cell carcinoma based in a review of the published literature. Long term survival after surgical treatment is possible in a patient with localized renal cell carcinoma extending into the right atrium. In patient with localized renal cell carcinoma and inferior vena cava tumor thrombus the cephalad extent of inferior vena caval involvement does not appear to influence the prognosis.

Circulating immune complexes in Buerger's disease. Endarteritis obliterans in young men

Auto-antibodies such as anti-elastin, anti-collagen, anti-nuclear and anti-arterial, circulating immune complexes, and cellular responses to collagen I and III are known to be present in Buerger's disease (EO). Deposits of IgG, C3 and C4 have also been found in the vascular lesions of endarteritis obliterans (EO) in young men. The purpose of this study was to correlate clinical evidence of vascular disease with the presence of the circulating immune complexes. Thirty-three patients suffering from Buerger's disease (EO), 20 patients suffering from atherosclerosis (AT) and 20 normal controls (Norm) were studied. All were male, heavy smokers, and age-matched. Five techniques were used: direct nephelometry, nephelometry with protamine, two polyethyleneglycol precipitation methods (PegIgG and PegC4), and an immuno-enzymatic C1q fixation test (C1qE). The results seem to confirm the presence of circulating immune complexes in peripheral arterial disease in young men who are heavy smokers, particularly those suffering from EO.