Heterotopic pregnancy (HP) is defined as the simultaneous development of an intra- and an extra uterine gestation. The occurrence of a spontaneous triplet HP is an exceptionally rare medical condition. We report the case of a young woman with spontaneous heterotopic triplets at 8 weeks of gestation, with a misdiagnosis of topic twins and acute appendicitis. The ectopic tubal pregnancy was ruptured and a salpingectomy was performed by laparotomy. The intrauterine pregnancy progressed uneventfully. The two healthy babies were delivery by cesarean section at 36 ± 2 weeks of gestation. Heterotopic triplets with ruptured tubal ectopic pregnancy represent a special diagnostic and therapeutic challenge for the obstetrician. A high rate of clinical suspicion and timely treatment by laparotomy or laparoscopy can preserve the intrauterine gestation with a successful outcome of the pregnancy.

Resumo A agenesia de carótida interna é uma anomalia rara. Na maioria dos casos, é assintomática devido às anastomoses que podem estar presentes, mas pode estar associada a complicações, principalmente quando evidenciada a presença de outras alterações anatômicas ou doença aterosclerótica grave. Relatamos o caso de uma paciente feminina de 63 anos, hipertensa e diabética, com história de cirurgia prévia para clipagem de aneurisma cerebral. Na investigação através de eco-Doppler e angiotomografia de carótidas e vertebrais, foi evidenciada agenesia unilateral da artéria carótida interna esquerda. Este relato objetiva chamar atenção para a importância de se suspeitar de malformações vasculares durante a investigação de quadros neurológicos. A agenesia de carótida interna tem uma importante associação com aneurismas intracerebrais, e é possível poupar o paciente de graves complicações quando estes são identificados a tempo.

Introduction Approximately 40 cases of spontaneous rupture of the aorta have been described in the literature. Diagnosis can be challenging, and a high index of clinical suspicion enabling prompt treatment can be lifesaving. Report This report presents the case of a 73 year old man who had three multilevel ruptures of the aorta at different times, all treated endovascularly. The patient had a good post-operative course, with no complaints during regular follow up. Discussion Clinical presentation was non-specific because the ruptures were contained, but spontaneous rupture of the aorta can manifest with a catastrophic presentation and hypovolaemic shock, requiring immediate treatment. The endovascular technique used was safe and resolved the patient's symptoms.

Adventitial cystic disease (ACD) of the radial artery is a rare condition, with few cases described in the literature. We report the case of a 62-year-old white male with a history of diabetes, hypertension, and chronic kidney disease with indications for renal replacement therapy who was found to have a cystic lesion of the radial artery while undergoing surgical creation of an arteriovenous fistula. The surgical technique adopted was resection of the cystic segment and preservation of the radial artery. Fistula creation was completed successfully. Early diagnosis and appropriate treatment of ACD are effective, and can prevent complications and recurrence.

Traditional treatment for great saphenous vein (GSV) insufficiency includes high ligation of the saphenofemoral junction and subsequent stripping of the GSV. However, the considerable morbidity and patient dissatisfaction associated with surgical treatment led to development of alternative techniques and intravenous laser treatment (EVLT) has emerged as a minimally invasive alternative to surgery. Formation of arteriovenous fistulas (AVF) during EVLT is extremely rare. In this study we report a case of AVF between a segment of the lateral accessory saphenous vein and the superficial femoral artery that was identified by ultrasound. Initially, two attempts were made at compression with a linear-array transducer without success, then alternatively surgery was performed without complications, leading to resolution of the AVF. This case report highlights the importance of ultrasound follow-up after EVLT, both for monitoring the effectiveness of the method and for diagnosis and early treatment of its complications.Keywords: varicose veins; laser therapy; ultrasonography; arteriovenous fistula. ResumoO tratamento tradicional da insuficiência da veia safena magna (VSM) inclui a ligadura alta na junção safeno-femoral combinada com a fleboextração. No entanto, a morbidade associada à insatisfação do paciente com esse tratamento tem conduzido ao desenvolvimento de técnicas alternativas, e a termoablação com laser endovenoso (EVLT) tornou-se uma alternativa minimamente invasiva à cirurgia. A formação de fístula arteriovenosa (FAV) durante o EVLT é extremamente rara. Neste estudo, relatamos um caso de identificação ecográfica de FAV entre um segmento da veia safena acessória lateral e a artéria femoral superficial. Optou-se inicialmente pela realização de duas tentativas de compressão com transdutor linear, sem sucesso, e alternativamente o procedimento cirúrgico foi realizado sem intercorrência e com resolução da FAV. Esse relato de caso evidencia a importância do seguimento de vigilância ecográfica após o EVLT tanto para o controle da efetividade do método como para o diagnóstico e tratamento precoce de suas complicações.Palavras-chave: varizes; terapia a laser; ultrassonografia; fístula arteriovenosa.

Introduction: Vascular access dysfunction and the depletion of access pathways are complications associated with morbidity and mortality in dialysis patients. As described in the literature, catheter insertion through small collateral veins or recanalized cervical and thoracic veins is an attractive option. Case Description: This article reports a case in which a collateral vein in the abdominal region was used as an access for hemodialysis. Conclusion: After multiple attempts with fistulas and catheters, the left abdominal wall collateral network proved to be a successful access site. Using unconventional veins can be an alternative in these patients.