Editor's Choice - Analysis of Lower Limb Amputations in Brazil's Public Health System over 13 Years.

OBJECTIVE: Understanding the causes of amputation is crucial for defining health policies that seek to avoid such an outcome, but only a few studies have investigated the epidemiology of patients submitted to amputations in developing countries. The objective of this study was to analyse all lower limb amputations performed in the public health system in Brazil over a 13 year period, evaluating trends in the number of cases, patient demographics, associated aetiologies, hospital length of stay, and in hospital mortality rate. METHODS: This was a retrospective, population based analysis of all lower limb amputations performed in the Brazilian public health system between 1 January 2008 and 31 December 2020. Using a public database, all types of amputations were selected, defining the number of procedures, their main aetiologies, anatomical level of limb loss, demographic data, regional distribution, and other variables of interest. RESULTS: A total of 633 455 amputations were performed between 2008 and 2020, mostly (55.6%) minor amputations, predominantly in males (67%). There was an upward trend in the number of amputations, determined mainly by the increase in major amputations (50.4% increase in the period). Elderly individuals have the highest rates of amputation. Diabetes mellitus (DM) is becoming the main primary diagnosis associated with amputations over the years. The highest in hospital mortality rate occurred after major amputations and was associated with peripheral arterial disease (PAD). CONCLUSION: Amputation rates in Brazil show an upward trend. DM is becoming the most frequent associated primary diagnosis, although PAD is the diagnosis most associated with major amputations and in hospital death.

Is routine screening for silent pulmonary embolism justified in patients with deep vein thrombosis?

The incidence of asymptomatic pulmonary embolism (PE) exceeds 70% in patients with deep venous thrombosis (DVT), even in cases of distal deep vein thrombosis. We report the case of a patient with a diagnosis of DVT in the lower left limb associated with asymptomatic PE who presented late symptoms due to this same PE. The absence of acute symptoms and the late onset of symptoms could have provoked doubts about the most appropriate treatment, resulting in unnecessary interventions, if pulmonary embolism had not already been diagnosed with tomography. In the present case, we demonstrate that computed tomography angiography conducted at the time of DVT diagnosis accurately diagnosed PE and prevented any misinterpretation of recurrent DVT in a patient already being medicated, which could have been mistakenly interpreted as demonstrating failure of anticoagulant therapy. Such a situation could lead to unnecessary intervention to fit an inferior vena cava filter. We cannot suggest that a classic medical conduct should be reformulated simply on the basis of a case report. However, we would be remiss not to suggest that well-designed studies should be carried out in the future to assess the need for this examination in the acute phase.

A ocorrência de embolia pulmonar assintomática em pacientes com trombose venosa profunda tem uma incidência que excede 70%, mesmo nos casos de trombose venosa profunda distal. Relatamos o caso de um paciente com diagnóstico de trombose venosa profunda no membro inferior esquerdo associado a embolia pulmonar assintomática, que apresentou sintomas tardios devido a essa mesma embolia. A ausência de sintomas agudos e o surgimento de sintomas tardios pode suscitar dúvidas quanto ao tratamento mais adequado e resultar em intervenções desnecessárias, se o diagnóstico tomográfico de embolia pulmonar não tiver sido feito anteriormente. No presente caso, demonstramos que uma angiotomografia realizada no momento do diagnóstico de trombose venosa profunda detectou a embolia pulmonar e evitou uma interpretação incorreta de um evento trombótico recorrente na vigência de anticoagulação, o que por engano demonstraria uma falha na terapia anticoagulante. Essa situação pode levar a intervenções desnecessárias, como o implante de filtro de veia cava inferior. Entendemos que apenas um relato de caso não deve mudar uma conduta médica já estabelecida; no entanto, fomenta a discussão e estimula estudos que avaliem a necessidade de um exame diagnóstico pulmonar no momento do diagnóstico de trombose venosa profunda.

Carbon Dioxide as Contrast Medium to Guide Endovascular Aortic Aneurysm Repair.

BACKGROUND: Iodine contrast medium (ICM) is considered to be gold standard in endovascular procedures, but its nephrotoxicity and hypersensitivity limit the widespread use. Carbon dioxide (CO2) is considered as an alternative for endovascular procedures in patients with contraindication to ICM. However, no studies have compared the outcomes of endovascular aneurysm repair (EVAR) performed with ICM or CO2 among patients with no contraindication to ICM. METHODS: From May 2012 to April 2014, 36 patients with abdominal aortic aneurysms underwent EVAR in a prospective, randomized, and controlled study. Patients were randomized into 2 groups, CO2 or ICM group. RESULTS: We were able to perform the proposed procedures in all patients in this study. There were no conversions to open surgery and no CO2-related complications. Endovascular material costs, duration of surgery, and time of fluoroscopy were similar between groups, and the cost of the contrast media was smaller in the CO2 group than in the ICM group. Among CO2 group procedures, 62.5% of the patients needed ICM complementary use. CONCLUSIONS: The use of CO2 as a contrast medium for EVAR is an alternative in patients with no restriction for ICM, with similar outcomes when compared to ICM, regarding duration of surgery, duration of fluoroscopy, and endovascular material costs. Using CO2, there were no changes in creatinine clearance and no risk of hypersensitivity reactions; moreover, there was a reduction in contrast-related costs for EVAR procedures. However, in our study, additional use of ICM to visualize the internal iliac artery was needed in most procedures.

Carbon dioxide is a cost-effective contrast medium to guide revascularization of TASC A and TASC B femoropopliteal occlusive disease.

BACKGROUND: Iodine contrast medium (ICM) is considered gold standard in endovascular revascularization procedures. However, nephrotoxicity and hypersensitivity to ICM are causes that limit its indiscriminate use. Carbon dioxide (CO2) contrast angiography has been used as an alternative in patients with formal contraindication to ICM. However, no studies to the present date have compared in a randomized and prospective way, outcomes of revascularization procedures performed with either ICM or CO2 in patients eligible for use of both contrasts. METHODS: Between April 2012 and April 2013, 35 patients with peripheral arterial disease with arterial lesions classified as Trans-Atlantic Inter-Society Consensus A or B (identified on preoperative angio computed tomography scan) and adequate runoff underwent femoropopliteal revascularization by endovascular technique in a prospective, randomized, and controlled study. Patients were randomized into 2 groups: CO2 group and ICM group, according to the contrast media selected of the procedure. We evaluated the following outcomes in both groups: feasibility of the procedures, complications, surgical outcomes (ankle-brachial index [ABI]), glomerular filtration rate using the Cockcroft-Gault formula, relationship between the volume of injected iodine and postoperative creatinine clearance, quality of the angiographic images obtained with CO2, costs of the endovascular materials, and finally, cost of contrast agents. RESULTS: We were able to perform the proposed procedures in all patients treated in this series (ICM group and CO2). There were no CO2-related complications. No procedures required conversion to open surgery. Clinical results were satisfactory, with regression of ischemia and increased levels of ABI in both groups. Variations in creatinine clearance levels showed a numerical increase in the CO2 group and a decrease in ICM group, however, with no statistically significant difference between the delta clearance in each group. All CO2 arteriograms of the supragenicular arteries were graded as good or fair by both observers with high interobserver image quality concordance. There was no statistical difference between endovascular material costs between the groups, but the contrast cost was significantly lower in CO2 group (P < 0.001). CONCLUSIONS: The use of CO2 in patients with no restriction for ICM is an alternative that does not limit the feasibility of the procedures. Similar outcomes were observed with CO2 when compared with the gold standard contrast (ICM) regarding quality of images produced, with no associated changes in creatinine clearance or hypersensitivity reactions and also allows a reduction in contrast-related costs in angioplasty procedures.

Technical difficulties and complications of sympathectomy in the treatment of hyperhidrosis: an analysis of 1731 cases.

BACKGROUND: The aim of this study was to ascertain the technical difficulties and complications of video-assisted thoracic sympathectomy (VTAS) in the treatment of hyperhidrosis in a large group of patients. METHODS: Between October 1995 and February 2008, 1731 patients with palmar, axillary, or craniofacial hyperhidrosis, who were treated using bilateral VTAS, were studied. We assessed the technical difficulties, early and late complications, and the approaches that were used to resolve them. RESULTS: Therapeutic success was achieved in 91% of the cases as evidenced by anhidrosis. The most common and severe technical difficulty during the procedure was pleural adhesions in 116 cases (6.7%); azygos lobes were seen in 7 patients (0.4%) and apical blebs in 3 patients (0.2%). The most frequent postoperative immediate complication was postoperative pain in 1685 (97.4%) patients; pneumothorax with chest drainage was seen in 60 cases (3.5%), neurologic disorders involving the upper limbs in 36 cases (2.1%), Horner's syndrome in 11 cases (0.9%), significant bleeding in 8 cases (0.4%), and 1 patient had extensive subcutaneous emphysema. The most frequent late complication was compensatory hyperhidrosis, which occurred in 1531 cases (88.4%). Although 27.2% of the patients reported severe compensatory hyperhidrosis, only 2.5% expressed regret for undergoing surgery. Gustatory sweating occurred in 334 patients (19.3%). No deaths occurred in this series. CONCLUSIONS: VTAS is safe and has shown good results. The major complication is compensatory hyperhidrosis and, when severe, the patient may express regret for undergoing surgery. Improvements in instrumentation, adequate training, and careful patient selection may help to reduce the number of drawbacks associated with VTAS.

Videothoracoscopic-guided management of a central vein perforation during hemodialysis catheter placement.

We present a case of the successful repair of an iatrogenic central vein lesion using a videothoracoscopic approach. The confluence of the right innominate vein and the superior vena cava was perforated during the placement of a right internal jugular vein long-term dialysis catheter. The misplacement of the tips of the catheter in the right pleural space was promptly observed. The catheter was removed under pleural videothoracoscopic vision while a tamponade was directly applied to the mediastinal perforation. Massive bleeding was prevented and the central vein perforation was treated successfully using a minimally invasive technique.

The therapeutic challenge of giant splenic artery aneurysm: a case repport.

Giant splenic artery aneurysm is a rare condition that represents an eminent life threatening for the patient, requiring, therefore, urgent surgical correction. A 61-year-old woman, former smoker, hypertensive, hypercholesterolemic and multipara sought our service because of a large tumor in the mesogastrium, which was an abdominal ultrasound finding. Despite the size of the tumor, the patient was asymptomatic. The angiotomography and the magnetic resonance image of the abdomen were suggestive of giant splenic artery aneurysm with more than 10cm in diameter that was confirmed by an angiography. She underwent surgery, open splenectomy, and partial aneurysmectomy. The approach of the celiac artery, which was ligated, was only possible with medialvisceral rotation because there was no possibility to view it through the anterior access. The histopathological test of aneurysmatic wall revealed atheroma plaques in the intima. The patient progressed without complications and she was discharged cured. In general, giant splenic artery aneurysms are symptomatic, however, as in the case we report, it may be asymptomatic and found in abdominal imaging exam. Although less invasive Interventional methods exist, such as laparoscopy and endovascular techniques, they were considered inappropriate in this case. Conventional open surgery should be the therapy of choice for a giant splenic artery aneurysm.

Axillary hyperhidrosis: T3/T4 versus T4 thoracic sympathectomy in a series of 276 cases.

BACKGROUND: Different techniques of video-assisted thoracic sympathectomy have been suggested to control the symptoms of axillary hyperhidrosis. We compared the results using two different levels of ganglion resection for treating axillary hyperhidrosis: T3/T4 vs. T4. MATERIALS AND METHODS: From a group of 1119 patients operated on between July 2000 and January 2005, 276 patients with axillary hyperhidrosis were studied. The mean age was 26 (range, 13-54 years) and 61.6% were female. Of these patients, 216 (78.3%) were treated with thermal ablation of T3/T4 and 60 (21.7%) with thermal ablation of T4 alone. The procedures were bilateral and simultaneous, using two 5.5-mm trocars and 30-degree optical systems, under general anesthesia in all cases. RESULTS: There was no mortality and no important postoperative complications or need to convert to thoracotomy in either group. The mean follow-up in the T4 group was 11 months (range, 2-23 months) and in the T3/T4 group mean follow-up was 24 months (range, 13-54 months). The immediate therapeutic success rate was 100% in both groups. There were recurrences in 7 (2.5%) patients, all from the T3/T4 group. The satisfaction rate was higher and more stable in the T4 group and compensatory sweating was lower in the T4 group. CONCLUSION: Both techniques proved effective for controlling the axillary symptoms. Group T4 presented a higher satisfaction rate, lower recurrence rate, and lower severity of compensatory sweating.

Endovascular revascularization of TASC C and D femoropopliteal occlusive disease using carbon dioxide as contrast.

OBJECTIVE: To analyze the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO2 as primary contrast in patients with no formal contraindication to iodine, aiming to decrease allergic reactions and potential nephrotoxicity in high-risk patients. METHODS: We describe the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO2 as primary contrast in patients with high risk for open revascularization and no formal contraindication to iodine. We analyzed feasibility of the procedures, complications, quality of the angiographic images, clinical and surgical outcomes, and costs of C and D lesions treated using CO2 as contrast medium. RESULTS: The use of CO2 in C and D lesions needed iodine complementation in most of the cases (nine cases) but decreased the potential nephrotoxicity of iodine contrast medium by the reduction of its volume in this group of high-risk patients. The extension of the arterial lesions was the factor that most contributed to the need for iodine supplementation due to the difficulty to visualize the refill after a long arterial occlusion. CONCLUSION: The use of CO2 as contrast in patients with C and D lesions with no restriction for iodine contrast medium was an alternative that did not dismiss the need of iodine supplementation in most of the cases, but could decrease the potential nephrotoxicity of iodine constrast medium. OBJETIVO: Analisar os resultados de dez angioplastias de lesões fêmoro-poplíteas TASC C e D utilizando CO2 como meio de contraste primário em pacientes sem restrição ao meio de contraste iodado com o objetivo de diminuir reações alérgicas e potencial de nefrotoxicidade em pacientes de alto risco. MÉTODOS: Descrevemos os resultados de dez angioplastias de lesões fêmoro-poplíteas TASC C e D utilizando CO2 como meio de contraste primário em pacientes de alto risco para revascularização aberta e sem contraindicação formal a iodo. Analisamos possibilidade de execução dos procedimentos, complicações, qualidade das imagens obtidas, desfechos clínicos e cirúrgicos e custos das lesões C e D tratadas com CO2 como meio de contraste. RESULTADOS: O uso de CO2 nas lesões C e D necessitou de complementação de iodo na maioria dos casos (nove casos), porém reduziu o potencial de nefrotoxicidade do meio de contraste iodado, diminuindo seu volume nesse grupo de pacientes de alto risco. A extensão das lesões arteriais foi o fator que mais contribuiu para necessidade de suplementação de iodo, devido à dificuldade de visualizar o reenchimento após oclusão arterial longa. CONCLUSÃO: O uso de CO2 como contraste em pacientes com lesões C e D sem restrição ao meio de contraste iodado foi uma alternativa que não excluiu a necessidade de suplementação com iodo na maioria dos casos, porém pôde diminuir o potencial de nefrotoxicidade do meio de contraste iodado.

Is routine screening for silent pulmonary embolism justified in patients with deep vein thrombosis? / Existe justificativa para o rastreio de embolia pulmonar silenciosa em pacientes com trombose venosa profunda?

Abstract The incidence of asymptomatic pulmonary embolism (PE) exceeds 70% in patients with deep venous thrombosis (DVT), even in cases of distal deep vein thrombosis. We report the case of a patient with a diagnosis of DVT in the lower left limb associated with asymptomatic PE who presented late symptoms due to this same PE. The absence of acute symptoms and the late onset of symptoms could have provoked doubts about the most appropriate treatment, resulting in unnecessary interventions, if pulmonary embolism had not already been diagnosed with tomography. In the present case, we demonstrate that computed tomography angiography conducted at the time of DVT diagnosis accurately diagnosed PE and prevented any misinterpretation of recurrent DVT in a patient already being medicated, which could have been mistakenly interpreted as demonstrating failure of anticoagulant therapy. Such a situation could lead to unnecessary intervention to fit an inferior vena cava filter. We cannot suggest that a classic medical conduct should be reformulated simply on the basis of a case report. However, we would be remiss not to suggest that well-designed studies should be carried out in the future to assess the need for this examination in the acute phase.

Resumo A ocorrência de embolia pulmonar assintomática em pacientes com trombose venosa profunda tem uma incidência que excede 70%, mesmo nos casos de trombose venosa profunda distal. Relatamos o caso de um paciente com diagnóstico de trombose venosa profunda no membro inferior esquerdo associado a embolia pulmonar assintomática, que apresentou sintomas tardios devido a essa mesma embolia. A ausência de sintomas agudos e o surgimento de sintomas tardios pode suscitar dúvidas quanto ao tratamento mais adequado e resultar em intervenções desnecessárias, se o diagnóstico tomográfico de embolia pulmonar não tiver sido feito anteriormente. No presente caso, demonstramos que uma angiotomografia realizada no momento do diagnóstico de trombose venosa profunda detectou a embolia pulmonar e evitou uma interpretação incorreta de um evento trombótico recorrente na vigência de anticoagulação, o que por engano demonstraria uma falha na terapia anticoagulante. Essa situação pode levar a intervenções desnecessárias, como o implante de filtro de veia cava inferior. Entendemos que apenas um relato de caso não deve mudar uma conduta médica já estabelecida; no entanto, fomenta a discussão e estimula estudos que avaliem a necessidade de um exame diagnóstico pulmonar no momento do diagnóstico de trombose venosa profunda.

Rediscussing Anticoagulation in Distal Deep Venous Thrombosis.

BACKGROUND: Distal deep venous thrombosis (DVT) accounts for approximately half of all the cases of lower limb thrombosis. The impact and management of this condition is still controversial. This study aims to evaluate the incidence of pulmonary embolism (PE) in patients with distal DVT in comparison to proximal DVT and evaluate the correlation between DVT and PE extension. METHODS: 100 patients with acute lower limb DVT diagnosed with whole leg Doppler ultrasound from January 2006 to December 2014 were retrospectively analyzed. Active investigation for PE was carried out in all patients using multislice computed tomography angiography. Classification of DVT and PE was based on the proximal extension of the thrombus. RESULTS: The overall incidence of PE in our sample patients was 72%. In the subgroup analysis, incidence of PE was equal in both the proximal and distal DVT groups (77%, p > 0.99). PE was detected in 43% of the patients with isolated calf vein thrombosis (ICVT). No statistical difference was observed between the distribution of lobar, segmental and subsegmental PE in the 3 DVT subgroups (p = 0.665); however, truncular PE was only observed in the proximal DVT group. CONCLUSION: Distal DVT is associated with a high incidence of PE compared to proximal DVT. Distal DVT and ICVT can provoke PE with involvement of proximal vessels in the pulmonary arterial tree, even in asymptomatic patients. Our study arises discussion in the controversial debate regarding the need for routine anticoagulation in distal DVT.

Enoxaparin Treatment Followed by Rivaroxaban for the Treatment of Acute Lower Limb Venous Thromboembolism: Initial Experience in a Single Center.

Rivaroxaban is a target-specific oral anticoagulant approved for the treatment of venous thromboembolism (VTE). On its major clinical trials, treatment was initiated directly with a 3-week dose of oral 15 mg twice daily followed by 20 mg every day for at least 3 months. We retrospectively evaluated an initial therapy for confirmed VTE with 1 to 18 days of enoxaparin (1 mg/kg twice daily parenteral) followed by oral rivaroxaban 20 mg every day. Of 49 patients, we found no symptomatic recurrence, no major bleeding, and only 1 clinically relevant nonmajor bleeding. We concluded in this pilot study that it is safe and effective to treat patients with enoxaparin course followed directly by a dose of 20 mg of rivaroxaban.

Randomized trial of radiofrequency ablation versus conventional surgery for superficial venous insufficiency: if you don't tell, they won't know.

OBJECTIVES:: This study compared radiofrequency ablation versus conventional surgery in patients who had not undergone previous treatment for bilateral great saphenous vein insufficiency, with each patient serving as his own control. METHOD:: This was a randomized controlled trial that included 18 patients and was carried out between November 2013 and May 2015. Each of the lower limbs of each patient was randomly assigned to undergo either radiofrequency ablation or conventional surgery. Clinical features (hyperpigmentation, hematoma, aesthetics, pain, skin burn, nerve injury, and thrombophlebitis) were evaluated at one week, one month, and six months postoperatively. Hemodynamic assessments (presence of resection or occlusion of the great saphenous vein and recurrent reflux in the sapheno-femoral junction and in the great saphenous vein) were performed at one month, six months, and 12 months postoperatively. The independent observer (a physician not involved in the original operation), patient, and duplex ultrasonographer were not made aware of the treatment done in each case. Clinicaltrials.gov: NCT02588911. RESULTS:: Among the clinical variables analyzed, only the aesthetic evaluation by the physicians was significant, with radiofrequency ablation being considered better than conventional surgery (average, 0.91 points higher: standard deviation: 0.31; 95% confidence interval: -1.51, -0.30; p=0.003). However, in our study, we observed primary success rates of 80% for radiofrequency ablation and 100% for conventional surgery. CONCLUSIONS:: If the physician is not required to inform the patient as to the technique being performed, the patient will not be able to identify the technique based on the signs and symptoms. Our study revealed that both techniques led to high levels of patient satisfaction, but our results favor the choice of conventional surgery over radiofrequency ablation, as patients who underwent conventional surgery had better hemodynamic assessments.

Carbon dioxide contrast medium for endovascular treatment of ilio-femoral occlusive disease.

OBJECTIVES: Compare the use of carbon dioxide contrast medium with iodine contrast medium for the endovascular treatment of ilio-femoral occlusive disease in patients without contraindications to iodine. MATERIALS AND METHODS: From August 2012 to August 2014, 21 consecutive patients with ilio-femoral occlusive disease who were eligible for endovascular treatment and lacked contraindications to either iodine contrast or carbon dioxide were randomized into the carbon dioxide or iodine groups and subjected to ilio-femoral angioplasty.We analyzed the feasibility of the procedures, the surgical and clinical outcomes, the procedure lengths, the endovascular material costs, the contrast costs and the quality of the angiographic images in each group. RESULTS: No conversions to open surgery and no contrast media related complications were noted in either group. A post-operative femoral pulse was present in 88.9% of the iodine group and 80% of the carbon dioxide group. No differences in procedure length, endovascular material cost or renal function variation were noted between the groups. Four patients in the carbon dioxide group required iodine supplementation to complete the procedure. Contrast media expenses were reduced in the carbon dioxide group. Regarding angiographic image quality, 82% of the carbon dioxide images were graded as either good or fair by observers. CONCLUSIONS: The use of carbon dioxide contrast medium is a good option for ilio-femoral angioplasty in patients without contraindications to iodine and is not characterized by differences in endovascular material costs, procedure duration and surgical outcomes. In addition, carbon dioxide has lower contrast expenses compared with iodine.

Carbon dioxide as a substitute for iodine contrast in arteriography during embolectomy.

Acute limb ischemia can be potentially harmful to the limb and life threatening. Renal failure is a possible outcome associated with release of products of ischemic limb reperfusion. Some authors reported the benefit of performing angiography after embolectomy, even though iodine contrast is also nephrotoxic. We report a case of embolectomy on a patient with renal insufficiency in whom carbon dioxide was used as a substitute for iodine contrast.

Public private partnership in vascular surgery.

OBJECTIVE: To describe and analyze the results of a public-private partnership between the Ministry of Health and a private hospital in a project of assistance and scientific research in the field of endovascular surgery. METHODS: The flows, costs and clinical outcomes of patients treated in a the public-private partnership between April 2012 and July 2013 were analyzed. All patients underwent surgery and stayed at least one day at the intensive care unit of the private hospital. They also participated in a research protocol to compare two intravenous contrast media used in endovascular surgery (iodinated contrast and carbon dioxide). RESULTS: A total of 62 endovascular procedures were performed in 57 patients from the public healthcare system. Hospital and endovascular supplies expenses were significantly higher as compared to the amount paid by the Unified Health System (SUS - Sistema Único de Saúde) in two out of three disease groups studied. Among outpatients, the average interval between appointment and surgery was 15 days and, in hospitalized patients 7 days. All procedures were successful with no conversion to open surgery. The new contrast medium studied - carbon dioxide - was effective and cheaper. CONCLUSION: The waiting time for patients between indication and accomplishment of surgery was significantly reduced. Public-private partnerships can speed up care of patients from public health services, and generate and improve scientific knowledge.

Cystic adventitial disease of the popliteal artery: an infrequent cause of intermittent claudication.

Intermittent claudication is frequently associated with atherosclerotic disease, but differential diagnosis must be sought in patients with no traditional risk factors. Cystic adventitial disease, of unknown etiology, most frequently affects the popliteal artery, and occasionally presents as intermittent claudication. We report a case of this disease and the surgical treatment, and discuss some aspects related to etiopathogenesis, diagnosis and treatment of this condition.

Risk of asymptomatic pulmonary embolism in patients with deep venous thrombosis.

OBJECTIVE: The aim of our study is to evaluate the incidence of asymptomatic pulmonary embolism (PE) in patients with deep venous thrombosis (DVT), submitted to routine angiography of pulmonary vessels, and analyze the relationship between the site of DVT and extent of PE. METHODS: Between January 2006 and April 2012, 52 consecutive patients with acute inferior limb DVT were divided into two study groups composed of individuals with proximal and distal thrombotic involvement. All patients had no respiratory symptoms and were submitted to routine pulmonary computed tomography angiography for active investigation of PE. We assessed the incidence and extent of PE in both study groups. RESULTS: Thirty-eight patients (72%) had PE, detected by computed tomography angiography. The incidence of PE in patients with proximal and distal thrombosis, respectively, was 72.7% and 73.7%. Occurrence of segmental embolism was equally high in both groups, affecting 71.4% of the patients with distal thrombosis and 66.6% of the individuals with proximal DVT (P > .99). CONCLUSIONS: The incidence of asymptomatic PE observed in patients with DVT is higher than what is reported in the current literature. This supports the importance of screening and the need for high levels of suspicion regarding this complication.

The therapeutic challenge of giant splenic artery aneurysm: a case repport / O desafio terapêutico do aneurisma gigante da artéria esplênica: um relato de caso

ABSTRACT Giant splenic artery aneurysm is a rare condition that represents an eminent life threatening for the patient, requiring, therefore, urgent surgical correction. A 61-year-old woman, former smoker, hypertensive, hypercholesterolemic and multipara sought our service because of a large tumor in the mesogastrium, which was an abdominal ultrasound finding. Despite the size of the tumor, the patient was asymptomatic. The angiotomography and the magnetic resonance image of the abdomen were suggestive of giant splenic artery aneurysm with more than 10cm in diameter that was confirmed by an angiography. She underwent surgery, open splenectomy, and partial aneurysmectomy. The approach of the celiac artery, which was ligated, was only possible with medialvisceral rotation because there was no possibility to view it through the anterior access. The histopathological test of aneurysmatic wall revealed atheroma plaques in the intima. The patient progressed without complications and she was discharged cured. In general, giant splenic artery aneurysms are symptomatic, however, as in the case we report, it may be asymptomatic and found in abdominal imaging exam. Although less invasive Interventional methods exist, such as laparoscopy and endovascular techniques, they were considered inappropriate in this case. Conventional open surgery should be the therapy of choice for a giant splenic artery aneurysm.

RESUMO O aneurisma gigante da artéria esplênica constitui condição rara, que representa risco de vida iminente para o paciente, necessitando, consequentemente, de correção cirúrgica urgente. Mulher de 61 anos, ex-fumante, hipertensa, com hipercolesterolêmica e multípara nos procurou por apresentar grande tumor no mesogástrio, achado de ultrassonografia abdominal. Apesar das dimensões do tumor, era assintomática. Angiotomografia e ressonância magnética de abdômen sugeriam tratar-se de aneurisma gigante de artéria esplênica com mais de 10cm de diâmetro, confirmado por angiografia. Foi submetida a tratamento cirúrgico aberto, tendo sido realizadas esplenectomia e aneurismectomia parcial. A abordagem do tronco celíaco, que foi ligado, só foi possível com rotação visceral medial, pois não havia possibilidade de visualizá-lo pela via anterior. O exame anatomopatológico da parede do saco aneurismático revelou placas de ateroma na íntima. A paciente evoluiu sem intercorrências e teve alta hospitalar curada. Aneurismas da artéria esplênica de dimensões avantajadas, em geral, são sintomáticos, porém, como no caso em questão, podem ser assintomáticos e descobertos em exame de imagem do abdômen. Apesar de existirem métodos intervencionistas menos invasivos, como laparoscopia e técnicas endovasculares, eles não foram considerados adequados neste caso. Diante de um aneurisma gigante de artéria esplênica, a conduta terapêutica de eleição é a cirurgia convencional aberta.

Endovascular revascularization of TASC C and D femoropopliteal occlusive disease using carbon dioxide as contrast / Revascularização endovascular de doença oclusiva fêmoro-poplítea TASC C e D com o uso de dióxido de carbono como meio de contraste

ABSTRACT Objective To analyze the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO2 as primary contrast in patients with no formal contraindication to iodine, aiming to decrease allergic reactions and potential nephrotoxicity in high-risk patients. Methods We describe the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO2 as primary contrast in patients with high risk for open revascularization and no formal contraindication to iodine. We analyzed feasibility of the procedures, complications, quality of the angiographic images, clinical and surgical outcomes, and costs of C and D lesions treated using CO2 as contrast medium. Results The use of CO2 in C and D lesions needed iodine complementation in most of the cases (nine cases) but decreased the potential nephrotoxicity of iodine contrast medium by the reduction of its volume in this group of high-risk patients. The extension of the arterial lesions was the factor that most contributed to the need for iodine supplementation due to the difficulty to visualize the refill after a long arterial occlusion. Conclusion The use of CO2 as contrast in patients with C and D lesions with no restriction for iodine contrast medium was an alternative that did not dismiss the need of iodine supplementation in most of the cases, but could decrease the potential nephrotoxicity of iodine constrast medium.

RESUMO Objetivo Analisar os resultados de dez angioplastias de lesões fêmoro-poplíteas TASC C e D utilizando CO2 como meio de contraste primário em pacientes sem restrição ao meio de contraste iodado com o objetivo de diminuir reações alérgicas e potencial de nefrotoxicidade em pacientes de alto risco. Métodos Descrevemos os resultados de dez angioplastias de lesões fêmoro-poplíteas TASC C e D utilizando CO2 como meio de contraste primário em pacientes de alto risco para revascularização aberta e sem contraindicação formal a iodo. Analisamos possibilidade de execução dos procedimentos, complicações, qualidade das imagens obtidas, desfechos clínicos e cirúrgicos e custos das lesões C e D tratadas com CO2 como meio de contraste. Resultados O uso de CO2 nas lesões C e D necessitou de complementação de iodo na maioria dos casos (nove casos), porém reduziu o potencial de nefrotoxicidade do meio de contraste iodado, diminuindo seu volume nesse grupo de pacientes de alto risco. A extensão das lesões arteriais foi o fator que mais contribuiu para necessidade de suplementação de iodo, devido à dificuldade de visualizar o reenchimento após oclusão arterial longa. Conclusão O uso de CO2 como contraste em pacientes com lesões C e D sem restrição ao meio de contraste iodado foi uma alternativa que não excluiu a necessidade de suplementação com iodo na maioria dos casos, porém pôde diminuir o potencial de nefrotoxicidade do meio de contraste iodado.