Grayscale median (GSM) post-processing, posterizing, and color mapping for carotid ultrasound.

Factors related to atherosclerotic plaques may indicate instability, such as ulcerations, intraplaque hemorrhages, lipid core, thin or irregular fibrous cap, and inflammation. The grayscale median (GSM) value is one of the most widespread methods of studying atherosclerotic plaques and it is therefore important to comprehensively standardize image post-processing. Post-processing was performed using Photoshop 23.1.1.202. Images were standardized by adjusting the grayscale histogram curves, setting the darkest point of the vascular lumen (blood) to zero and the distal adventitia to 190. Posterization and color mapping were performed. A methodology that presents the current state of the art in an accessible and illustrative way should contribute to the dissemination of GSM analysis. This article describes and illustrates the process step by step.

Shear wave elastography for extracranial carotid atherosclerotic plaques: technical principles and how to do it.

In the wake of studies targeting atherosclerotic plaques and searching for quantifiable variables that contribute additional information to therapeutic decision-making, plaque assessment using Shear Wave Elastography (SWE) is emerging as a reproducible and promising alternative. We used a single Logiq S8 device (General Electric, Boston, Massachusetts, United States) with an 8.5-11MHz multifrequency linear transducer at 10MHz in longitudinal section. We considered relevant criteria for image acquisition: adequate longitudinal insonation, differentiation of the intima-media complex, delineation of proximal and distal tunica adventitia and the vascular lumen, good visualization of the atherosclerotic plaque, cardiac cycle in ventricular diastole, and absence of incongruous changes. SWE is an emerging and extremely promising method for assessment of carotid plaques that may contribute to therapeutic decision-making based on characteristics related to the atherosclerotic plaque, with inter-device and inter-examiner reproducibility.

Comparative study of angiographic changes in diabetic and non-diabetic patients with peripheral arterial disease.

Background: Diabetics are at 5-15 times greater risk of developing peripheral arterial disease (PAD) and few studies have compared risk factors and distribution and severity of arterial changes in diabetics compared with non-diabetics. Objectives: To compare angiographic changes between diabetic and non-diabetic patients with advanced PAD and correlate them with risk factors. Methods: A retrospective cross-sectional study was conducted of consecutive patients undergoing lower limb arteriography for PAD (Rutherford 3-6) using TASC II and Bollinger et al. angiographic scores. Exclusion criteria were upper limb angiographies, unclear images, incomplete laboratory test results, and previous arterial surgeries. Statistical analyses included chi-square tests, Fisher's test for discrete data, and Student's t test for continuous data (significance level: p < 0.05). Results: We studied 153 patients with a mean age of 67 years, 50.9% female and 58.2% diabetics. A total of 91 patients (59%) had trophic lesions (Rutherford 5 or 6) and 62 (41%) had resting pain or limiting claudication (Rutherford 3 and 4). Among diabetics, 81.7% were hypertensive, 29.4% had never smoked, and 14% had a history of acute myocardial infarction. According to the Bollinger et al. score, infra-popliteal arteries were more affected in diabetics, especially the anterior tibial artery (p = 0.005), while the superficial femoral artery was more affected in non-diabetics (p = 0.008). According to TASC II, the most severe angiographic changes in the femoral-popliteal segment occurred in non-diabetic patients (p = 0.019). Conclusions: The most frequently affected sectors were the infra-popliteal sectors in diabetics and the femoral sector in non-diabetics.

In-situ bypass is associated with superior infection-free survival compared with extra-anatomic bypass for the management of secondary aortic graft infections without enteric involvement.

OBJECTIVE: The optimal revascularization modality following complete resection of aortic graft infection (AGI) without enteric involvement remains unclear. The purpose of this investigation is to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients undergoing complete excision of AGI. METHODS: A retrospective, multi-institutional study of AGI from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and perioperative variables were recorded. The primary outcome was infection-free survival. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariable analyses were performed. RESULTS: A total of 241 patients at 34 institutions from seven countries presented with AGI during the study period (median age, 68 years; 75% male). The initial aortic procedures that resulted in AGI were 172 surgical grafts (71%), 66 endografts (27%), and three unknown (2%). Of the patients, 172 (71%) underwent complete excision of infected aortic graft material followed by in situ (in-line) bypass (ISB), including antibiotic-treated prosthetic graft (35%), autogenous femoral vein (neo-aortoiliac surgery) (24%), and cryopreserved allograft (41%). Sixty-nine patients (29%) underwent extra-anatomic bypass (EAB). Overall median Kaplan-Meier estimated survival was 5.8 years. Perioperative mortality was 16%. When stratified by ISB vs EAB, there was a significant difference in Kaplan-Meier estimated infection-free survival (2910 days; interquartile range, 391-3771 days vs 180 days; interquartile range, 27-3750 days; P < .001). There were otherwise no significant differences in presentation, comorbidities, or perioperative variables. Multivariable Cox regression showed lower infection-free survival among patients with EAB (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), polymicrobial infection (HR, 2.2; 95% CI, 1.4-3.5; P = .001), methicillin-resistant Staphylococcus aureus infection (HR, 1.7; 95% CI, 1.1-2.7; P = .02), as well as the protective effect of omental/muscle flap coverage (HR, 0.59; 95% CI, 0.37-0.92; P = .02). CONCLUSIONS: After complete resection of AGI, perioperative mortality is 16% and median overall survival is 5.8 years. EAB is associated with nearly a two and one-half-fold higher reinfection/mortality compared with ISB. Omental and/or muscle flap coverage of the repair appear protective.

Short-Term Outcomes of Transfemoral Carotid Artery Stenting and Carotid Endarterectomy in Symptomatic Patients: Data from a Multicentric Prospective Registry in Brazil.

BACKGROUND: Transfemoral carotid artery stenting (TF-CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. Because their main objective is to prevent future ischemic events, regular reassessment of the outcomes is mandatory for providing the best therapy. The purpose of this study was to describe the practice and the outcomes of TF-CAS and CEA in symptomatic patients in public university hospitals in Brazil, using data from a prospective multicentric registry. METHODS: A prospective 8-year observational study of patients with symptomatic carotid artery atherosclerotic disease that underwent TF-CAS and CEA in 5 public university hospitals affiliated with the RHEUNI (Registry Project of Vascular Disease in the Public University Hospitals of São Paulo). All consecutive procedures were included. The indications for the procedures were determined by each surgeon's individual discretion, in accordance with a preoperative risk evaluation. The outcome measures were any 30-day follow-up death, stroke, myocardial infarction (MI), and their combined outcome (major adverse cardiovascular events [MACE]). The registration of the study was made at clinicaltrials.gov NCT02538276. RESULTS: From January 2012 through December 2019, 376 consecutive and symptomatic patients were included in the study records. There were 152 TF-CAS procedures (40.4%) and 224 CEA procedures (59.5%). All completed the 30-day follow-up period. Occurrence of death (TF-CAS: 0.66% × CEA: 0.66%, P = 0.99), stroke (TF-CAS: 4.61% × CEA: 4.46%, P = 0.99), and MI (TF-CAS: 0.66% × CEA: 0%, P = 0.403) were similar in both groups, without statistically significant differences. MACE rate did not differ in both groups (TF-CAS: 5.92% × CEA: 4.46%, P = 0.633). CONCLUSIONS: Data from a prospective registry of 5 Brazilian university hospitals showed that TF-CAS and CEA in symptomatic patients had similar 30-day perioperative rates of death, stroke, and MI and their combination.

Unibody design for aortic disease with a narrow aortic bifurcation: tips and tricks for success.

BACKGROUND: Surgical management of patients with abdominal aortic diseases associated with distal narrowing is a challenging situation. OBJECTIVES: To evaluate outcomes of unibody bifurcated endovascular stent graft repair. METHODS: This is a retrospective, observational, multi-institutional database study of a cohort of consecutive cases, approved by the local Ethics Committee. Records were reviewed of patients diagnosed from 2010 to 2020 with "shaggy" aorta, saccular aneurysm, penetrating aortic ulcer, and isolated aortic dissection located in the infrarenal abdominal aorta. All patients were treated with a unibody bifurcated stent graft. Main outcomes were technical success, procedure complications, long-term patency, and mortality in the follow-up period up to 5 years. Data on demographics, comorbidities, surgical management, and outcomes were analyzed. RESULTS: Twenty-three patients were treated with unibody bifurcated stent graft repair, including 7 cases of "shaggy" aorta, 3 isolated dissections of the abdominal aorta, 4 penetrating aortic ulcers, and 9 saccular aneurysms. Immediate technical success was achieved in 100% of cases. At follow-up, all stent grafts remained patent and there were no limb occlusions. The patients were symptom-free and reported no complications related to the procedure. There were 5 deaths during the follow-up period (median= 4 years), but none were related to the procedure and there were no aorta-related deaths. CONCLUSIONS: The present study shows that unibody bifurcated stent grafting is safe and effective in this group of patients with narrow distal abdominal aorta and complex aortic pathology. The results were similar for both infrarenal aortic aneurysms and aorto-iliac atherosclerotic disease.

CONTEXTO: O manejo cirúrgico de pacientes com doenças da aorta abdominal associadas ao estreitamento distal é desafiador. OBJETIVOS: Avaliar os desfechos do reparo endovascular com endoprótese bifurcada do tipo monobloco. MÉTODOS: Foi realizado um estudo retrospectivo, de coorte observacional, de banco de dados multi-institucional, com casos consecutivos, após aprovação pelo Comitê de Ética local. Foram analisados prontuários de pacientes com diagnóstico de shaggy aorta, aneurisma sacular, úlcera penetrante da aorta e dissecção isolada da aorta localizados na aorta abdominal infrarrenal entre 2010 e 2020; todos os pacientes foram tratados com endoprótese bifurcada do tipo monobloco. Os principais desfechos foram sucesso técnico, complicações relacionadas ao procedimento, perviedade de longo prazo e mortalidade no seguimento de até 5 anos. Foram incluídos dados demográficos, comorbidades, manejo cirúrgico e desfechos. RESULTADOS: Vinte e três pacientes foram tratados com endoprótese bifurcada do tipo monobloco, incluindo 7 casos de shaggy aorta, 3 dissecções isoladas da aorta abdominal, 4 úlceras penetrantes da aorta e 9 aneurismas saculares. Sucesso técnico imediato foi obtido em 100% dos casos. No seguimento, todas as endopróteses permaneceram pérvias e não houve oclusões de membros. Os pacientes estavam sem sintomas e não relataram complicações relacionadas ao procedimento. Ocorreram 5 óbitos durante o seguimento (mediana = 4 anos), mas nenhum relacionado ao procedimento ou à aorta. CONCLUSÕES: O presente estudo mostra que a endoprótese bifurcada do tipo monobloco é segura e eficaz neste grupo de pacientes com estreitamento distal da aorta abdominal e patologia aórtica complexa. Os resultados foram semelhantes para aneurismas da aorta infrarrenal e doença aterosclerótica aortoilíaca.

True isolated deep femoral artery aneurysm associated with peripheral artery disease: case report.

True deep femoral artery aneurysms are extremely rare, accounting for about 0.5% of all peripheral aneurysms. In this report, we describe a 79-year-old male patient with a history of prior abdominal aortic aneurysm surgery via a conventional approach who was admitted to the vascular surgery service at the Hospital das Clínicas with intermittent claudication of the lower limbs. Arterial color-Doppler ultrasonography of the right lower limb was performed, revealing peripheral arterial disease of the femoral--popliteal and infrapatellar segments. Computed tomography angiography identified aortoiliac and bifurcated graft occlusion from the infrarenal segment of the aorta, in addition to a deep femoral artery aneurysm with diameters of 3.7 cm x 3.5 cm and length of 7 cm. Resection of the aneurysm was followed by revascularization of the deep femoral artery by interposition of a Dacron® graft and reimplantation of the superficial femoral artery into the graft. In cases of deep femoral artery aneurysms with concomitant peripheral arterial disease, it is important to ensure revascularization and adequate perfusion of the lower limb.

Endovascular treatment with aortic endoprostheses for subclavian artery aneurysm secondary to late traumatic axillary-axillary arteriovenous fistula.

Traumatic arteriovenous fistulas (AVFs) involving the axillary and subclavian vessels are uncommon and account for 5 to 10% of all arterial traumas. The complex anatomy of this region makes treatment of this segment challenging. In this therapeutic challenge, we describe the case of a 73-year-old man, referred for progressive edema and ulceration involving the right upper limb and with a history of gunshot wound to the right infraclavicular region about 50 years previously. Angiotomography was performed and an axillary-axillary AVF was found, associated with tortuosity and aneurysmatic dilation of the subclavian artery downstream. He underwent endovascular intervention and a conical (monoiliac) 26 × 14 × 90 mm Braile® endoprosthesis was used in the aneurysmatic subclavian artery, posterior to the exit of the right vertebral artery and a 16 × 16 × 95mm Excluder® monoiliac endoprosthesis was placed overlapping the first prosthesis, showing a satisfactory result. Therefore, the possibility of successfully using aortic endoprostheses in an unusual and exceptional situation is described.

Endovascular treatment of portal hypertension and recurrent digestive hemorrhage secondary to arterioportal fistula syndrome: late complication of penetrating abdominal trauma.

The arterioportal fistula (APF) syndrome is a rare and reversible cause of pre-sinusoidal portal hypertension, caused by communication between a visceral artery and the portal venous system. Most patients are asymptomatic, but when they do develop symptoms, these are mainly related to gastrointestinal bleeding, ascites, congestive heart failure, and diarrhea. This therapeutic challenge presents a case of APF caused by a 20-year-old stabbing injury with unfavorable late clinical evolution, including significant malnutrition and severe digestive hemorrhages. The patient was treated using an endovascular procedure to occlude of the fistula.

Results of treatment of acute occlusions of limb arteries at a university hospital - retrospective study.

BACKGROUND: Acute arterial occlusions (AAO) in limbs have been increasing in parallel with population longevity. OBJECTIVE: To assess risk factors, limb salvage rates, and survival of patients with AAO treated at a University Hospital. METHODS: Retrospective cohort study of consecutive patients. Outcomes included: patency, symptoms, comorbidities, Rutherford category, arteries occluded, postoperative complications, and 30-day limb salvage and mortality rates. RESULTS: Medical records were evaluated from 105 patients, predominantly males (65.7%), with ages ranging from 46 to 91 years. Etiology: thrombotic (54.3%), embolic (35.2%), and undefined (10.5%). About 2/3 of the patients were assessed as Rutherford category II or III. Associated symptoms: pain (97.1%), coldness (89.5%), pallor (64.7%), sensory loss (44.7%), paralysis (30.5%), anesthesia (21.9%), edema (21.9%), and cyanosis (15.2%). Associated comorbidities: hypertension (65.0%), smoking (59.0%), arrhythmias (26.6%), dyslipidemia (24.0%), and diabetes (23.8%). The distal superficial femoral-popliteal segment was the most affected (80%). Thromboembolectomy with a Fogarty catheter was performed in 73.3% of cases (81.0% of embolic cases, 71.9% of thrombotic cases, and 54.5% of cases with undefined etiology) and was the only treatment used in 41 cases (39.05%), among which there were 11 reocclusion, 20 amputations, and 14 deaths. Arterial reocclusion was more frequent in thrombosis cases (12.9%, p = 0.054). Within 30 days of treatment, total mortality was 14.6%, and 19.8% of cases underwent major amputation, which was less frequent among Rutherford Class I patients (p = 0.0179). CONCLUSION: Treatment of AAO was primarily performed by thromboembolectomy with a Fogarty catheter, either alone or in combination with other treatments, achieving amputation and complication rates compatible with the best results in the literature and were progressively lower in less advanced Rutherford categories.

Alprostadil associated with low molecular weight heparin to treat limb ischemia caused by SARS-CoV2.

The current coronavirus pandemic has already taken a great toll globally, causing massive morbidity and mortality. One of its severe forms is a thrombophilic state that can damage several systems. This article reports the case of 60-year-old female patient who presented with mild flu symptoms, which turned out to be a SARS-CoV2 infection, and ended up developing arterial thrombosis with limb ischemia in a private care hospital in Sorocaba, São Paulo, Brazil. Considering this progression, we decided to intervene with low molecular weight heparin and Alprostadil, achieving a good clinical outcome. Our description aims to identify key points and clinical signs that offer evidence of the therapeutic window and a treatment option for coagulatory presentations of COVID-19.

A atual pandemia de coronavírus já gerou danos profundos ao redor do mundo, causando grande quantidade de morbidades e mortes. Uma das manifestações das formas graves da doença é o estado trombofílico, que pode provocar danos em vários sistemas. Este artigo relata o caso de uma paciente do sexo feminino, 60 anos de idade, que foi internada em um serviço hospitalar privado com sintomas gripais inespecíficos leves, mas que progrediu com trombose arterial e isquemia de membros causada pelo SARS-CoV2. Devido à essa evolução, foi optada pela administração concomitante de heparina de baixo peso molecular e Alprostadil, com bom desfecho clínico. Nossa descrição objetiva identificar pontos-chave e sinais clínicos que evidenciem essa janela terapêutica, bem como uma opção de tratamento para as apresentações coagulatórias da COVID-19.

Acute aortic wall injury caused by aortic cross-clamping: morphological and biomechanical study of the aorta in a swine model of three aortic surgery approaches.

BACKGROUND: Aortic cross-clamping and balloon occlusion of the aorta could lead to damage to the aorta wall. OBJECTIVE: The aim of this study was to investigate changes to the aorta wall related to the method used to interrupt flow (clamping or balloon) in the different techniques available for aortic surgery. METHODS: Experiments were performed on 40 female pigs, weighing 25-30kg, which were randomly allocated to 4 study groups: S (n=10), no intervention (sham group); C (n=10), midline transperitoneal laparotomy for infrarenal abdominal aortic access with 60 min of cross-clamping; L (n=10), laparoscopic infrarenal abdominal aortic surgery with 60 min of cross-clamping; EV (n=10), remote proximal aortic control with transfemoral arterial insertion of aortic occlusion balloon catheter, inflated to provide continued aortic occlusion for 60min. After euthanasia, the aortas were removed and cross-sectioned to obtain histological specimens for light microscopic and morphometric analyses. The remaining longitudinal segments were stretched to rupture and mechanical parameters were determined. RESULTS: We observed a reduction in the yield point of the abdominal aorta, decrease in stiffness and in failure load in the aortic cross-clamping groups (C and L) compared with the EV group. CONCLUSIONS: Aortic cross-clamping during open or laparoscopic surgery can affect the mechanical properties of the aorta leading to decrease in resistance of the aorta wall, without structural changes in aorta wall histology.

Venous thromboembolism, can we do better? Profile of venous thromboembolism risk and prophylaxis in a University Hospital in the State of São Paulo.

BACKGROUND: Venous thromboembolism (VTE) is a silent and potentially lethal disease that affects a considerable proportion of hospitalized patients. It has high morbidity and mortality and is responsible for a heavy financial burden on healthcare systems. However, VTE can be prevented using prophylaxis measures that have been established in the literature. Nonetheless, in the real world, mean rates of appropriately administered VTE prophylaxis are lower than 50%. OBJECTIVES: To define the epidemiological profile of patients with VTE in a University Hospital and the rate of appropriately administered VTE prophylaxis at that service and to identify measures to improve the rate. METHODS: A cross-sectional, observational study was conducted with data collected from the medical records of patients who met the inclusion criteria. The rates of correct VTE prophylaxis prescribed to clinical and surgical patients were compared, assessed according to guidelines published by the Brazilian Society of Angiology and Vascular Surgery (SBACV), based on VTE risk classification. RESULTS: The overall rate of correctly-prescribed VTE prophylaxis was 42.1%, while 57.9% of patients were not managed correctly in this respect. Clinical patients had a 52.9% rate of appropriate prophylaxis, while the equivalent rate for surgical patients was 37.5%. CONCLUSIONS: Rates of correctly-prescribed VTE prophylaxis are still lower than they should be. Ongoing education, measures to encourage bedside risk stratification, and improvements to the electronic prescription system could increase appropriate VTE prophylaxis rates.

Results of One-Stage or Staged Amputations of Lower Limbs Consequent to Critical Limb Ischemia and Infection.

BACKGROUND: Amputations of lower limbs can be conducted as one-stage amputation (OSA) or staged amputation (SA) procedures. The objective of this study was to analyze technical success and mortality rates of both techniques, as well as factors that might influence outcomes in patients with critical limb ischemia (CLI). METHODS: A retrospective study of 185 consecutive patients with CLI who underwent amputations in the period 2004-2011. Primary end points were rates of technical success (healing without dehiscence or reintervention) and mortality. The influence on outcomes of demographic data, clinical status, and comorbidities was also analyzed by logistic regression. RESULTS: A total of 101 SA (91 patients) and 106 OSA (94 patients) were analyzed. SA had proportionally higher success rate (SA 77.2% vs. OSA 66.0%, P = 0.0253), lower perioperative mortality rate (SA, 10.9% vs. OSA, 20.7%, P = 0.0247), and lower 30-day mortality rate (SA, 12.2% vs. OSA, 23.8%, P = 0.0220) in spite of more cases with Rutherford classes 5 and 6 (SA, 87.1% vs. OSA, 72.6%, P = 0.0047), diabetes (71.2% vs. 55.6%, P = 0.0076), and infection (44.5% vs. 28.3%, P = 0.0061). Logistic regression demonstrated that in SA, success was more frequent in patients with diabetes who did not use insulin (P = 0.0072), in those with transfemoral amputations (P = 0.0392), with no coronary artery disease (P = 0.0053), and in foot infection (P = 0.0446), while for OSA success was more frequent in nondiabetic patients (P = 0.0077), limbs without infection (P = 0.0298), amputations at foot level (P = 0.0155), or transfemoral amputations (P = 0.0030). CONCLUSIONS: SA had a higher rate of technical success and lower mortality rates than OSA, even with greater number of patients with diabetes and more severe cases of ischemia and infection. However, prospective studies comparing both techniques are needed for further evidence.

Inferior gluteal artery pseudoaneurysm after fall from a bicycle: case report.

Pseudoaneurysms of gluteal arteries are rare, especially involving the inferior gluteal artery. They are mainly associated with penetrating trauma, infections, or pelvic fractures. A minority of cases are caused by blunt traumas, with only six cases reported in English. We present a case of pseudoaneurysm of the right inferior gluteal artery after a bicycle fall, presenting with a large hematoma in the gluteal region, observed during clinical examination, and significantly reduced hemoglobin. CT angiography revealed a large hematoma, with contrast extravasation and pseudoaneurysm formation. Angiography revealed that the origin of the lesion was in the right inferior gluteal artery. This artery was embolized with coils. After the procedure, the patient was referred to an intensive care unit, from where he was later transferred to a different hospital, with bleeding controlled. Endovascular treatment of these cases is a safe, fast and an effective option.

An Unexpectedly High Rate of Thrombophilia Disorders in Patients with Superficial Vein Thrombosis of the Lower Extremities.

BACKGROUND: Superficial vein thrombosis (SVT) is a common venous condition. Recent studies have shown that SVT is associated with high frequency of thromboembolic complications: from 22-37% for deep venous thrombosis and up to 33% for pulmonary embolism. Our goal was to assess the prevalence of major hereditary and acquired thrombophilic factors in patients with SVT. METHODS: Sixty-six patients presenting with primary SVT underwent evaluation for thrombophilia: molecular testing for the factor V Leiden and factor II G20210 A (prothrombin) mutations, protein C, protein S, antithrombin deficiency, presence of lupus anticoagulant, as well as anticardiolipin antibody titers. Patients aged less than 18 years, with confirmed deep vein thrombosis, and pregnant women were excluded. RESULTS: 95.5% were Caucasian, and 62.1% were female gender. Age ranged from 21-88 years. Molecular testing showed that 34.2% of patients were heterozygous for factor V Leiden, 23.6% were heterozygous for the factor II mutation, 7.8% had antithrombin deficiency, 2.6% had protein S deficiency, and 2.1% had protein C deficiency. CONCLUSIONS: Our study showed that hereditary and acquired thrombophilias are higher than previously expected and reported.

Endovascular treatment of spontaneous isolated common and external iliac artery dissections with preservation of pelvic blood flow.

Spontaneous isolated dissection of iliac arteries is very rare, with few reports in the literature. Medical, surgical, and endovascular treatment modalities have all been used to manage iliac artery dissections. We report a case of symptomatic, isolated, spontaneous dissection of the common iliac and external iliac arteries. Both dissections were successfully treated by separate percutaneous stent-graft placement, preserving hypogastric artery flow. This technique is interesting because it provides adequate sealing of proximal and distal dissection sites while preserving hypogastric artery and pelvic flow.

Systematic review of randomized controlled trials of new anticoagulants for venous thromboembolism prophylaxis in major orthopedic surgeries, compared with enoxaparin.

BACKGROUND: In the past 10 years, new anticoagulants (NACs) have been studied for venous thromboembolism (VTE) prophylaxis. OBJECTIVE: To evaluate the risk/benefit profile of NACs versus enoxaparin for VTE prophylaxis in major orthopedic surgery. METHODS: A systematic review of double-blind randomized phase III studies was performed. The search strategy was run from 2000 to 2011 in the main medical electronic databases in any language. Independent extraction of articles was performed by 2 authors using predefined data fields, including study quality indicators. RESULTS: Fifteen published clinical trials evaluating fondaparinux, rivaroxaban, dabigatran, and apixaban were included. Primary efficacy (any deep vein thrombosis [DVT], nonfatal pulmonary embolism, or all-cause mortality) favored fondaparinux (relative risk [RR] 0.50; 95% CI, 0.39, 0.63) and rivaroxaban (RR, 0.50; 95% CI, 0.34, 0.73) over enoxaparin, although significant heterogeneity was observed in both series. The primary efficacy of dabigatran at 220 mg, apixaban, and bemiparin were similar, with RRs of 1.02 (95% CI, 0.86, 1.20), 0.63 (95% CI, 0.39, 1.01), and 0.87 (95% CI, 0.65, 1.17), respectively. The primary efficacy of dabigatran at 150 mg (RR, 1.20; 95% CI, 1.03, 1.41), was inferior to enoxaparin. The incidence of proximal DVT favored apixaban (RR, 0.45; 95% CI, 0.27, 0.75) only. Rivaroxaban (RR, 0.45; 95% CI, 0.27, 0,77) and apixaban (RR, 0.38; 95% CI, 0.16, 0.90) produced significantly lower frequencies of symptomatic DVT. The incidence of major VTE favored rivaroxaban (RR, 0.44; 95% CI, 0.25, 0.81), only. Bleeding risk was similar for all NACs, except fondaparinux (RR, 1.27; 95% CI, 1.04, 1.55), which exhibited a significantly higher any-bleeding risk compared with enoxaparin, and apixaban (RR, 0.88; 95% CI, 0.79, 0.99), which was associated with a reduced risk of any bleeding. Alanine amino transferase was significantly lower with 220 mg of dabigatran, (RR, 0.67; 95% CI, 0.79, 0.99) than with enoxaparin. CONCLUSIONS: NACs can be considered alternatives to conventional thromboprophylaxis regimens in patients undergoing elective major orthopedic surgery, depending on clinical characteristics and cost-effectiveness. The knowledge of some differences concerning efficacy or safety profile, pointed out in this systematic review, along with the respective limitations, may be useful in clinical practice.

Ulcer due to chronic venous disease: a sociodemographic study in northeastern Brazil.

BACKGROUND: Venous ulcers account for 70% of chronic leg ulcers and affect about 2-7% of the population, causing much socioeconomic impact and reducing patients' quality of life. In this study we aimed to describe the clinical features of venous ulcers and sociodemographic characteristics of patients with ulcers due to chronic venous disease (CVD). METHODS: This cross-sectional, observational study was conducted at the Vascular Surgery Service, Universidade Federal de Sergipe, in northeastern Brazil. The study included a consecutive series of 154 patients with active venous ulcers (CEAP C6) in the lower limb due to CVD. Sociodemographic characteristics (age, gender, race, monthly income, education, occupation, and caregiver) and clinical data (affected limb, ulcer site, etiopathogenesis, recurrence, and time elapsed since the first episode of ulcer) were collected. A possible correlation of time elapsed since the first episode of ulcer and number of recurrences with primary or secondary etiology was analyzed by Mann-Whitney U-test. RESULTS: Of the 154 patients analyzed, 79% were female, 94% were ethnically black or brown, 90% had a monthly income less than or equal to minimum wage, 47% were illiterate, 35% had not completed elementary school, 50% had informal jobs, 19.5% were retired, and 18.2% received sick pay from the social security system. The mean age was 53.7 years. Both limbs were affected similarly, and venous ulcers were located predominantly on the medial aspect of the leg (84%). The median time elapsed since the first episode of ulcer was 36 months, being significantly higher in patients with venous ulcers of secondary etiology (P < 0.0003). The prevalence of recurrence was also significantly higher in patients with venous ulcers of secondary etiology (P < 0.001). According to CEAP classification, 65% of ulcers were primary (Ep), 94.1% demonstrated reflux involving the superficial system (As), 92% had incompetent perforators (Ap), 35% demonstrated reflux involving the deep system (Ad), and all ulcers showed reflux without obstruction (Pr). CONCLUSIONS: Venous ulcers were more prevalent among low-income patients, especially chronic, recurrent ulcers of primary etiology. This finding highlights the need for improvements in patient care and surgical treatment in most cases aimed at ulcer healing and reduced recurrence. Better care would improve patients' quality of life and reduce social security expenditures.

Morphologic and biomechanical changes of thoracic and abdominal aorta in a rat model of cigarette smoke exposure.

BACKGROUND: Smoking is the most relevant environmental factor that affects the development of aortic aneurysm. Smokers have elevated levels of elastase activity in the arterial wall, which leads to weakening of the aorta. The aim of this study was to verify whether cigarette smoke exposure itself is capable of altering the aortic wall. METHODS: Forty-eight Wistar rats were divided into 2-, 4-, and 6-month experimental periods and into 2 groups: smokers (submitted to smoke exposure at a rate of 40 cigarettes/day) and nonsmokers. At the end of the experimental periods, the aortas were removed and cross-sectioned to obtain histologic specimens for light microscopic and morphometric analyses. The remaining longitudinal segments were stretched to rupture and mechanical parameters were determined. RESULTS: A degenerative process (i.e., a reduction in elastic fibers, the loss of lamellar arrangement, and a reduction of smooth muscle cells) was observed, and this effect was proportional in intensity to the period of tobacco exposure. We observed a progressive reduction in the yield point of the thoracic aorta over time (P < 0.05). There was a decrease in stiffness (P < 0.05) and in failure load (P < 0.05) at 6 months in the abdominal aorta of rats in the smoking group. CONCLUSIONS: Chronic exposure to tobacco smoke can affect the mechanical properties of the aorta and can also provoke substantial structural changes of the arterial wall.