Abstract Introduction Patent foramen ovale (PFO) closure has emerged as a secondary prevention option in patients with PFO and cerebrovascular events. Despite its seemingly established efficacy, its associated long-term outcomes – including safety – remain unclear. Purpose To ascertain the extent to which PFO percutaneous closure is able to improve long-term clinical outcomes in patients with cryptogenic vascular events. Methods We systematically searched MEDLINE, Embase and Cochrane CENTRAL for randomized controlled trials (RCTs) and observational studies comparing PFO percutaneous closure with antithrombotic therapy, in what concerns recurrent cerebrovascular and serious adverse events, as well as mortality. A composite of stroke and transient ischemic attack (TIA) was the primary endpoint. Data related to RCTs, patients with high-risk PFO features, subjected to PFO closure with the most represented device and with antiplatelet therapy as control were further investigated separately. Study-specific odds ratios (ORs) were pooled using traditional meta-analytic techniques, under a random- (DerSimonian-Laird method) or a fixed-effects (Mantel-Haenszel method) model. Results Literature search yielded 2145 references, of which 26 – 8 regarding RCTs – were included. Patients undergoing PFO closure reached 4304, whereas 4180 were treated with antithrombotic therapy. PFO closure was significantly associated with lower stroke/TIA recurrence (OR 0.35 [0.24–0.53], I2=58%). Moreover, such reduction met statistical significance for both stroke (OR 0.34 [0.21–0.54], I2=29%) and TIA (OR 0.53 [0.34–0.82], I2=39%), individually. Subgroup analyses focusing only on RCTs and on studies featuring the most represented device confirmed these trends, while the effects were even more pronounced in patients with high-risk PFO characteristics and in those controlled with antiplatelet therapy. On the other hand, PFO closure was not associated with neither lower all-cause (OR 0.76 [0.46–1.27], I2=0%) nor lower cardiovascular mortality (OR 0.92 [0.37–2.29], I2=0%). Moreover, neither a composite of serious adverse events (SAEs) (OR 1.10 [0.94–1.29], I2=0%) nor major bleeding episodes (OR 0.75 [0.40–1.38], I2=23%) differed significantly between groups. However, PFO closure was associated with increased odds of procedure- or device-related complications (OR 12.94 [5.56–30.13], I2=0%) and atrial fibrillation or flutter (OR 3.35 [1.78–6.30], I2=30%). Conclusion In patients with history of cryptogenic vascular events, when compared with medical management, PFO percutaneous closure is indeed associated with a reduction in the odds of recurrent stroke and TIA. However, mortality seems not to be impacted by this apparently enhanced effect. While general SAEs and major bleeding are comparable between both approaches, PFO closure may bring upon procedure- or device-related complications and increase the odds of atrial fibrillation or flutter. Funding Acknowledgement Type of funding sources: None.

INTRODUCTION:Inflammation is a common underlying feature of atherosclerosis. Several inflammatory biomarkers have been reported to have prognostic value, in several areas, including in vascular surgery. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) may permit to identify patients at greater risk for cerebrovascular events, tailor patient management, improve preoperative status and possibly develop target anti-atherosclerotic therapy. However, studies reporting usefulness of these hematological biomarkers in the context of carotid artery disease are still scarce. The aim of this study was to review the literature concerning the prognostic ability of NLR and PLR in the subpopulation of vascular patients with carotid artery disease.METHODS:A Medline search was performed in order to identify publications focused on the physiopathology of NLR and PLR and their impact in the management of patients with carotid artery disease.RESULTS:The study identified 18 articles with a total of 5339 patients. NLR is associated with carotid intima-media thickness, carotid plaques, carotid stenosis, symptomatic stenosis and intra-stent restenosis after carotid artery stenting and cognitive dysfunction after carotid endarterectomy. PLR is associated with carotid stenosis, symptomatic stenosis and predicts post-operative outcomes after carotid artery revascularization, including post-operative stroke, acute coronary syndrome and all-cause mortality.CONCLUSIONS:The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have the ability to predict sub-clinic atherosclerosis, atherosclerosis progression in carotid artery disease and propensity for carotid stenosis to become symptomatic along with morbidity following CEA and carotid stenting. Consequently, these parameters may be considered to tailored therapy and improve patient management.

Introduction Neutrophil-to-lymphocyte ratio (NLR) and platelet-to- -lymphocyte ratio (PLR) are useful markers for identifying inflammation, which is a common feature of atherosclerosis. Patients with carotid atherosclerosis are at greater risk for cerebrovascular events which cause significant morbidity and mortality. Objectives The aim of this review was to determine the prognostic ability of the NLR and the PLR in patients undergoing carotid endarterectomy (CEA). Materials and Methods A search was performed in Medline, Scopus and ISI web of knowledge in order to identify articles focused on these hematological parameters and their impact on the outcomes in patients undergoing CEA. The 30-day stroke and stroke/ death rates were retrieved. Additional demographic data was meta-analysed. Results Platelet-Lymphocyte ratio was associated with an increased 30-day stroke rate. Additionally, an increased PLR was associated with symptomatic internal carotid artery stenosis and postoperative acute coronary syndrome in patients who underwent CEA. An elevated NLR was associated with an increased risk of cognitive dysfunction one day after CEA. Conclusions The NLR and PLR have prognostic value for carotid endarterectomy in the short term.

Introduction Jejunal artery aneurysms (JAA) are uncommon, mostly asymptomatic and many times incidental findings in imaging studies. The diagnosis before rupture is not always feasible, leading to high rupture rates of about 30%. Although endovascular repair is widely used in the treatment of these aneurysms, some patients still require open repair. Objectives Demonstrate the applicability of open repair in the correction of a JAA. Materials and Methods Report a case of a patient affected by JAA, successfully treated with open repair. Results A 44-year-old women with no previous relevant medical history was referred to the Vascular Surgery consultation with a suspicion of a JAA on a computed tomography (CT) scan made during the study of a persistent epigastric pain, with no other complaints. Abdominal palpation was painful in the epigastric region. Laboratory studies revealed no alterations. A CT angiography (CTA) was repeated in our Department and revealed a saccular aneurysm with 25x20 mm of diameter, in the proximal portion of the first jejunal artery. The exam also depicted a stenosis of 9 mm of extension in the celiac trunk, turning the hepatic perfusion dependent of the gastroduodenal artery flow. Endovascular repair was not suitable because of the location of the aneurysm and involvement of several arterial branches, which increased the risk of pancreatic, hepatic and intestinal ischemia. An open approach was decided. We confirmed intraoperatively the aneurysm gave rise to the inferior pancreatoduodenal artery and two duodenal branches (Figure 1). A tangential resection of the aneurysm was done, preserving the flow in the jejunal artery. Arterial closure was performed with lateroterminal anastomosis between the jejunal artery and the bevelled pancreatoduodenal artery. One of the duodenal branches was also re-implanted in the jejunal artery in a lateroterminal fashion. A continuous suture with a non-absorbable 6/0 suture were used for both anastomoses. At the end of the procedure no ischemic signs were evident in the duodenum and jejunum and it was decided to not re-implant the other duodenal branch. The patient's post-operative course was uneventful. One month after the surgery, the patient was asymptomatic, with no abdominal pain and CTA confirmed the patency of the reconstructed arteries. Conclusions All symptomatic JAAs and those >2 cm must be treated. Open approach has some advantages, including direct inspection for intestinal and hepatic ischemia and vascular re- -implantation, if necessary, as highlighted in this case.

Introduction: Despite advances in EVAR techniques and stent graft designs, aortic neck anatomy is still important to determine technical and long term clinical success. Among different features, severe neck angulation is associated with type Ia endoleak both in the perioperative period and in the long term [1, 2], when treated outside the instructions for use (IFUs) of standard devices. In order to overcome this unfavorable anatomy, non-conventional modalities have been explored, namely, the use of thoracic endografts at the proximal neck. Given their high radial force and conformability it has been hypothesized that they may provide adequate sealing in these scenarios. The literature on the use of thoracic endografts for severely angulated necks is almost non-existent and only a few case reports have been published do far.[3-5] No large studies have been undertaken and the perioperative and long-term technical and clinical success is therefore unknown. Until then it is advisable that patients treated with this technique be followed up closely.In this report we present a case of a large infra-renal abdominal aortic aneurysm (AAA) with a severely angulated neck treated with a thoracic endograft. Methods: An 82 year-old patient was admitted to our emergency department, due to a motorcycle crash related trauma. During abdominal ultrasound study, a 12cm AAA was detected. Trauma related injuries were a small subarachnoid hemorrhage which was spontaneously reabsorbed, without need for intervention. A computerized tomographic angiography (CTangio) was performed. A 12.5cm infra-renal AAA was detected. The neck was cylindrical in shape, with a diameter of 15mm and length of 20mm. No severe neck calcification or mural thrombus was present. Of notice, the infra-renal (b) angulation was 89º. The proximal aneurysm sac had an angulation of 84º. Such severe angulation precluded the use of standard commercially available EVAR devices. After overall health status assessment, the patient was deemed unfit for open surgery. The procedure was performed in the operating theater under regional anaesthesia. Access was performed through bilateral surgical cutdown. Left femoral endarterectomy and external iliac balloon angioplasty was performed due to critical obstructive atherosclerotic lesions. A 21 x 100mm Gore C-TAG endograft (W.L. Gore and Associated, Flagstaff, AZ) was deployed at the justa-renal end of the proximal neck, to adapt the neck angulation and provide adequate seal. A 23 x 120mm Gore C3 Excluder bifurcated main body graft was deployed inside the former. Bilateral 16mm iliac limbs were then deployed, in ballerina conformation, as it was technically less challenging in this case. Molding balloon angioplasty was performed. Completion angiography demonstrated no endoleaks and no limb, renal or hypogastric artery occlusion. Results: There were no perioperative complications and the patients was discharged on postoperative day 4. Follow up CTangio showed no endoleaks, device migration, limb kinking or occlusion. The patient is currently asymptomatic, after 6 months of follow up. Conclusion: The use of thoracic endografts in severely angulated infra-renal necks of AAA patients is a feasible solution. Further studies on this technique will need to be done to determine its durability and validate its application. Disclosure: Nothing to disclose

INTRODUCTION:Minimally invasive revascularization of the left anterior descending coronary artery has gained popularity. Recently, the emergence of new surgical instruments and the improvement of the technique, allowed its use by routine. Its use in Heart Team allows excellent results. Our aim is to present the results of patients undergoing this technique in our center.METHODS:Retrospective study of patients submitted to minimally invasive revascularization of the left anterior descending coronary artery at our center.RESULTS:We identified 14 patients. The mean age was 67 years old. In the total of the procedures, 79% were elective and 21% urgent. The ventricular function was preserved in 86% of the patients. In the preoperative catheterization, 64% of the patients showed single disease of the anterior descending coronary artery, 29% had trunk lesions and 3 vessels and 7% had lesion of 2 vessels. The mean Euroscore II was 4.8%. The mean time of surgery was 103 minutes with a mean blood loss of 250mL. The main complications were wound dehiscence and revision of hemostasis. The mean hospitalization rate was 6.2 days. The hospital survival rate was 100%.CONCLUSION:Minimally invasive revascularization allows coronary artery bypass grafting with the best conduit. Revascularization may be total in single disease of the left anterior descending artery, or in case of multivessel disease, achieved with hibrid revascularization, with angioplasty of the remaining vessels. This technique has shown to be promising and safe, being the discussion in Heart Team of the patient candidates essential for achieving the best results.

An 82 year old male was admitted with pain and a pulsatile mass in the right thigh, pyrexia, leucocytosis and raised C-reactive protein. History included previous admission with methicillin resistant Staphylococcus aureus (MRSA) bacteraemia. Computed tomographic angiography demonstrated an 86 × 57 × 101 mm mass, with active contrast extravasation in the medial region of the thigh and rupture of the superficial femoral artery (SFA). A below knee femoropopliteal bypass using reversed great saphenous vein was performed. The diseased SFA segment was resected. Antibiotic treatment was administered. Blood and arterial tissue cultures were positive for MRSA. However, the patient died of septic shock on day 22 of admission.

INTRODUCTION:Brachial artery aneurysms are relatively uncommon and generally due to infectious, post-traumatic or iatrogenic etiology. They seem to affect 4.5% of arteriovenous fistula. The usual manifestation is an accidental finding of a pulsatile, painless, and asymptomatic mass. Complications include sac thrombosis, thromboembolic ischaemic events, and disruption with profuse bleeding.METHODS:The aim of this study is to present a case of true brachial artery aneurysm in end-stage renal disease patient after arteriovenous fistula creation.RESULTS:Sixty-six-year-old men with a past medical history of hypertension, dyslipidemia, smoking and poliquistic renal disease. He started a hemodialysis program in March 2006, using a brachiocephalic fistula on the left upper limb, built in February 2005. Submitted to kidney transplant in June 2010 and subsequent fistula ligation in December 2012. He goes to the emergency service in June 2016 with a pulsatile mass on the medial aspect of the left arm. Pain, redness and heat were present. Radial pulse was palpable. Inflammatory parameters were high and ultrasound revealed a fusiform aneurysm of the brachial artery with partial thrombosis and triphasic flow. An MRI was performed, documenting a brachial artery aneurysm, with 44mm greatest diameter and an extension of 17.5cm. Patient was hospitalized under antibiotic therapy and submitted to a reversed great saphenous vein interposition graft. Discharge from hospital occurred on the 7th postoperative day, with no sensitive or motor deficits and a present radial pulse.CONCLUSION:Arterial aneurysm is a rare, but significant complication long after the creation of a hemodialysis access. High flow, immunosuppression and increased resistance following ligation of the AV fistula may accelerate this process.

INTRODUCTION:Popliteal artery entrapment is an uncommon syndrome, caused by extrinsic compression of the popliteal artery by muscular or tendinous structures. It occurs mainly in young individuals, with no atherosclerostic risk factors, and a mean age of presentation of 20 to 40 years, and has higher prevalence in males (83% of patients). Clinical presentation depends on the degree of arterial lesion, the most common being intermittent claudication, with critical ischemia being frequent. Occasionally, it may present as acute ischaemia.METHODS:A 40-year-old female patient, physical education teacher, presented with a history of left foot paresthesia and left calf muscle pain during jogging for one year. The patient used to previously run 10 kilometers, currently mentioning claudication at 500 meters. No other medical conditions were mentioned. Lower extremity arterial duplex ultrasound revealed left popliteal artery compression and occlusion during active plantar flexion and passive dorsal flexion. The patient was referred to a vascular surgery center. Physical examination revealed palpable bilateral lower extremity pulses, with left asymmetry. Lower limb angiography and magnetic resonance imaging (MRI) were performed which demonstrated left popliteal artery compression and occlusion during a resisted plantar flexion. MRI revealed no anatomic anomalies, pointing to a probable functional entrapment caused by calf muscle hypertrophy (typo VI).RESULTS:Entrapment correction surgery was performed through a posterior approach and exposure. During the procedure, the artery showed no signs of significant fibrosis. Since compression by the medial head of the gastrocnemius muscle was observed, myotomy of its lateral fibers was performed. The patient was discharged on the second day post-surgery. After three months, the patient remained free of symptoms, having taken up sports practice with no limitations.CONCLUSION:Continuous popliteal artery compression leads to its progressive fibrosis, which may cause thrombosis or post-stenotic aneurysmal dilation. Treatment should be performed as soon as possible as to avoid this course and the eventual necessity of interposition or bypass grafting. Futhermore, late intervention worsens the interposition/ bypass grafting prognosis5. In this sense, the possibility of this diagnosis should be considered in a young patient presenting with intermittent claudication. Diagnostic tests are often decisive for differential diagnosis and to establish the disease subtype and intervention strategy. In most patients, a culprit muscular or tendinous anomaly is detected before surgery, however, in some individuals, especially physically active ones, compression results from muscular hypertrophy.

INTRODUCTION:Hepatic artery aneurysms (HAAs) are rare, representing about 0.1-2% of all arterial aneurysms. They are the second most common splanchnic aneurysms, after splenic artery aneurysms. They have the highest rate of rupture among all splanchnic artery aneurysms and frequently become symptomatic.METHODS:To present a case of a hepatic artery aneurysm treated by endovascular technique.RESULTS:A 65-year old man who had a medical history of hypertension, dyslipidemia and smoking, with an incidental finding on a CT imaging of a hepatic artery aneurysm (maximum diameter 75mm) was admitted for selective arteriography and treatment. He was asymptomatic. We proceeded to aneurysm exclusion with a self-expandable covered stent (Viabahn®) 6x100mm. Final angiography revealed permeability of right hepatic artery, splenic artery and gastroduodenal artery, and no visible endoleaks. He was discharged on the 4th postoperative day, asymptomatic and without analytic changes. On a 6 months follow-up, CT-angio confirmed a fully patent stent with no visible endoleaks and complete aneurysm exclusion.CONCLUSION:HAAs should be diagnosed before rupture. Abdominal pain, bleeding or compression may be the first symptoms. Exclusion by endovascular techniques, namely through covered- stent use, may be a good option.

Microvascular dysfunction has been suggested to trigger adipose tissue dysfunction in obesity. This study investigates the hypothesis that glycation impairs microvascular architecture and expandability with an impact on insulin signalling. Animal models supplemented with methylglyoxal (MG), maintained with a high-fat diet (HFD) or both (HFDMG) were studied for periepididymal adipose (pEAT) tissue hypoxia and local and systemic insulin resistance. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) was used to quantify blood flow in vivo , showing MG-induced reduction of pEAT blood flow. Increased adipocyte size and leptin secretion were observed only in rats feeding the high-fat diet, without the development of hypoxia. In turn, hypoxia was only observed when MG was combined (HFDMG group), being associated with impaired activation of the insulin receptor (Tyr1163), glucose intolerance and systemic and muscle insulin resistance. Accordingly, the adipose tissue angiogenic assay has shown decreased capillarization after dose-dependent MG exposure and glyoxalase-1 inhibition. Thus, glycation impairs adipose tissue capillarization and blood flow, hampering its expandability during a high-fat diet challenge and leading to hypoxia and insulin resistance. Such events have systemic repercussions in glucose metabolism and may lead to the onset of unhealthy obesity and progression to type 2 diabetes.

INTRODUCTION:Amniotic membrane (AM) is an option as a cover in varicose leg ulcers, promoting epithelization. Anti-inflammatory and analgesic proprieties are described, as well as high levels of growth factors and angiogenesis. The costs are inferior to surgical plasty. The aim of this work is to describe the results of AM in the treatment of varicous leg ulcers in a group of patients refractory to the best medical treatment.METHODS:A pilot prospective trial was conducted. Thirteen patients were selected for the treatment with AM from an outpatient clinic. The inclusion criteria included: ulcer area inferior to 100 cm2, ulcer size variation inferior to 30% in the last month, duration superior to 2 years and refractory to best medical treatment including compressive therapy. The exclusion criteria were ABI>0,8m active infection, bone exposure, severe myopathy of the low limb and acute decompensation of systemic chronic disease. The first five cases were applied on the enfermary (mean stay 3 days), the last 8 patients were applied in the outpatient clinic. After the treatment behavioral reinforcement was made.RESULTS:The mean sample age was 56 YO (50-71), 70% were female, 30% were diabetic, and post-thrombotic syndrome was present in 54% (7), only one patient was an active smoker. After 2 years a recurrence was observed in 23% (3) cases.CONCLUSION:AM is effective in the treatment of varicose ulcers unresponsive to best medical treatment.

Aims/hypothesis: Microvascular dysfunction has been suggested as a trigger for adipose tissue (AT) dysfunction in obesity[1]. We investigated the role of glycation[2] in impairing AT capillarization, blood flow and expandability. Methods: We used an animal model of high-fat diet supplemented with methylglyoxal (HFDMG), compared with high-fat diet (HFD) or methylglyoxal (MG) alone and the type 2 diabetic Goto-Kakizaki rats (GK). Hypoxia, angiogenic pathways, insulin resistance and blood flow (through magnetic resonance imaging) were addressed. MG effects on AT capillarization were assessed through the AT angiogenesis assay. Results: Impaired adipose tissue blood flow was observed in groups with MG-induced glycation and GK rats, but not in the HFD group. Moreover, increased adipocyte size and leptin secretion in HFD rats were not followed by hypoxia development. Instead, this was observed in the HFDMG group, which also showed an impairment of hypoxia-response mechanisms and angiogenic pathways. HFDMG rats also had less insulin receptor activation (Tyr1163), glucose intolerance and systemic insulin resistance, similarly to diabetic rats. Accordingly, MG decreased ex vivo AT capillarization in a concentration-dependent manner. Conclusions: Glycation impairs AT capillarization and blood flow, hampering its expandability during a high-fat diet challenge and leading to hypoxia and insulin resistance.

Myokines are peptides produced and secreted by the skeletal muscle, with autocrine, paracrine, and endocrine actions. Many of them are overexpressed during physical exercise and appear to contribute to the benefits of exercise to metabolic homeostasis. Irisin, resulting from the cleavage of the membrane protein FNDC5, was shown to induce adipocyte browning, with increased lipid oxidation and thermogenesis. Myonectin was only recently discovered and initial studies revealed a role in fatty acid uptake and oxidation in adipose tissue and liver. However, the mechanisms of their regulation by exercise are not entirely established. Impaired secretion and action of myokines, such as irisin and myonectin, may have a role in the establishment of insulin resistance. On the other hand, several studies have shown that insulin resistance in the skeletal muscle may change myokines expression and secretion. This may have consequences on lipid and glucose metabolism in adipose tissue and lead to a vicious cycle between impaired myokines production and insulin resistance. This review summarizes the current knowledge about the influence of skeletal muscle insulin resistance on the secretion of irisin and myonectin, as well as its impact on adipose tissue metabolism.