A rare vascular injury in a blood donor after whole blood donation.

BACKGROUND: Blood donation is a safe process though reactions may still occur. We describe a rare vascular complication in a frequent donor, with improvements in the collection process aimed at avoiding future events. METHODS: A 63-year-old woman presented with local pain and an apparent collection in the left arm 8 days after donation. Duplex ultrasound identified a superficial liquid collection and signs of arteriovenous fistula (AVF) between the cubital vein and an arterial branch. A computed tomography (CT)-angio performed 1 day after ultrasound did not identify signs of AVF, followed by a new duplex which confirmed CT-angio findings. It was assumed that a traumatic AVF evolved with spontaneous thrombosis. In the early follow-up (18 days), a progressive regression of hematoma was observed without any sequelae. RESULTS: Investigation showed a faster whole blood bag collection time (3 min; normal: 5-9 min), and the processed packed red blood cell had a brighter red color than usual. The donor reported local bleeding after needle withdrawal, not observed in previous donations and a bruise forming on the same day. No arterial puncture (AP) was noticed by the collection staff during the procedure. The staff was retrained and actions were taken focusing on more active surveillance of late reactions, highlighting the importance of post-donation information by the donors, regardless of any adverse reaction observed, to detect late complications. CONCLUSION: We described an uncommon AP in a donor that was not identified, leading to an AVF that spontaneously thrombosed.

Endovascular Therapy Provides Similar Results of Bypass Graft Surgery in the Treatment of Infrainguinal Multilevel Arterial Disease in Patients with Chronic Limb-Threatening Ischemia in All GLASS Stages.

BACKGROUND: Extensive infrainguinal arterial disease still pose a challenge for technical and clinical success of percutaneous angioplasty. The purpose of this study was to compare the results of concomitant femoropopliteal and infrapopliteal percutaneous angioplasty/stenting (PTA/S) with distal bypass graft surgery (BGS) in patients with chronic limb-threatening ischemia (CLTI). METHOD: In a single-center retrospective investigation between 2011 and 2017, 668 revascularization procedures for CLTI were reviewed. Concomitant femoropopliteal and infrapopliteal disease was identified in 153 CLTI patients, treated with BGS (48) using autogenous veins as substitute or PTA/S in a single procedure (105). A subgroup of patients with complex, extensive arterial lesions (GLASS stage III) received additional analysis. Primary outcomes were limb salvage and survival. RESULTS: The mean follow-up time was 21.4 months. Patients treated with PTA/S were significantly older and with predominance of females, diabetes and chronic kidney disease. Smoking was more common in patients treated with BGS. The BGS group showed a 36-month survival rate of 73.4%, whereas the PTA/S group presented a survival of 61.3% in the same interval (P = 0.25). The 36-month cumulative limb salvage rate was 53.3 and 59.7% for BGS and PTA/S, respectively (P = 0.24). For GLASS stage III patients, 36-month limb salvage rates were 54.4% for the PTA/S group and 50.2% for the BGS group (P = 0.29). Multivariate analysis pointed poor runoff status (all endovascular patients) and diabetes (GLASS III endovascular patients) as risk factors for limb loss. CONCLUSION: PTA/S and BGS presented similar results of limb salvage and survival in the treatment of concomitant femoropopliteal and infrapopliteal arterial disease in patients with CLTI, even for patients with extensive and complex arterial disease.

Carotid Plaque Morphology in Asymptomatic Patients with and without Metabolic Syndrome.

BACKGROUND: The aim of this study was to determine the impact of metabolic syndrome (MetS) on the morphology of carotid plaques, as evaluated using duplex ultrasound (DUS) with computer-assisted analysis. METHODS: In this cross-sectional observational study, we analyzed 148 carotid artery plaques in asymptomatic patients. Data were obtained via clinical and laboratory examinations, and DUS was performed by a single operator. All plaques were scanned in a longitudinal fashion, and the best segment was selected, recorded, and evaluated using dedicated software. The main software-based analyses included gray-scale median (GSM) measurements and carotid plaque morphology histograms. RESULTS: MetS was identified in 51.8% of patients. Comparisons of patients with MetS and patients without MetS indicated that the former patients used more classes of antihypertensive drugs (2.49 vs. 1.93; P = 0.004) and were treated with statins for a longer period (71.08 vs. 49.17 months; P = 0.003). Most patients of both types exhibited moderate carotid artery stenosis ranging from 50% to 69% (n = 62; 37.3%), and MetS was not associated with an increased prevalence of severe carotid artery stenosis. The mean GSM was greater in the MetS group than in the non-MetS group (74.18 vs. 61.63; P = 0.012). The histogram analysis revealed that there were lower quantities of blood and fat (2.91 vs. 3.88; P = 0.006; 10.21 vs. 15.08; P = 0.004, respectively) and more fibrous tissue (19.93 vs. 14.55; P = 0.015) in the carotid plaques of patients with MetS than in the carotid plaques of patients without MetS. CONCLUSIONS: The present study demonstrated that MetS did not affect the stenosis grade or did it lead to unstable carotid plaques.

Comparison between a new computer program and the reference software for gray-scale median analysis of atherosclerotic carotid plaques.

PURPOSE: To compare a new dedicated software program and Adobe Photoshop for gray-scale median (GSM) analysis of B-mode images of carotid plaques. METHODS: A series of 42 carotid plaques generating ≥50% diameter stenosis was evaluated by a single observer. The best segment for visualization of internal carotid artery plaque was identified on a single longitudinal view and images were recorded in JPEG format. Plaque analysis was performed by both programs. After normalization of image intensity (blood = 0, adventitial layer = 190), histograms were obtained after manual delineation of plaque. Results were compared with nonparametric Wilcoxon signed rank test and Kendall tau-b correlation analysis. RESULTS: GSM ranged from 00 to 100 with Adobe Photoshop and from 00 to 96 with IMTPC, with a high grade of similarity between image pairs, and a highly significant correlation (R = 0.94, p < .0001). CONCLUSIONS: IMTPC software appears suitable for the GSM analysis of carotid plaques.

Technique of aortic replacement through endovascular stenting before aortic wall resection for primary leiomyosarcoma of the abdominal aorta.

Tumors involving the aorta represent a challenging situation because the surgical approach can lead to blood loss and/or clamping-related complications such as ischemia, thrombosis, or reperfusion syndromes. We describe the technique of aortic endograft placement to cover part of the abdominal aorta and provide conditions for extensive aortic wall resection, without clamping or blood loss, followed immediately by aortic reconstruction with bovine pericardium. This technique also allows the surgeon to wait for the results of freeze biopsy without additional clamping time, thus avoiding the risk of leaving residual tumor cells in the aortic wall.

A duplex scan-based morphologic study of the femoral vein: incidence and patterns of duplication.

The presence of femoral vein (FV) duplicity has potential influence in the misdiagnosis of deep vein thrombosis. Also, FVs are suitable vascular substitutes, especially in the substitution of infected prosthetic grafts. The objective of this study was to describe the prevalence, anatomic patterns and characteristics of FV duplicity in adult individuals by duplex scan examination. A total of 174 adult individuals were submitted to duplex-scan examinations of both lower limbs. Individuals with duplex signs of present or previous DVT or with poor quality duplex images were excluded from the investigation. The remaining group consisted of 157 individuals (94 females), with a total of 314 limbs studied. Along with the conventional duplex investigation sequence, the FV was scanned both in transversal and longitudinal views. The number, extension and diameter of FVs were documented. It was found that 173 limbs (55.1%) had duplicated FV. Duplicity in the whole femoral extension was noted in 82 (26.1%) limbs, and out of these only 28 (8.9% of the overall number) had accessory veins with a diameter approximate to (at least 75%) the main FV. Partial (distal or proximal) duplications were seen in 89 (28.3%) limbs. A third FV was present in 28 limbs. As a possible vascular substitute, 99.0% of the main FVs and 25.4% of the accessory veins presented diameters superior to 6 mm, a suitable value for iliac substitution. In conclusion, FV duplicity is frequent, and occurred in 55% of all limbs studied. However, complete extension duplicated veins with similar diameters was an uncommon condition, noticed in fewer than 10% of limbs.

Comparison of common carotid artery intima-media thickness between Brazilian Euro-descendants and Afro-descendants with atherosclerosis risk factors.

OBJECTIVE: To compare common carotid intima-media thickness (IMT) between the two major Brazilian ethnic groups (those of African descent and those of European descent) among individuals with one or more risk factors for atherosclerotic disease. METHOD: Two hundred and six patients with one or more risk factors for atherosclerotic disease were evaluated in a cross-sectional study in which their clinical, ethnic and Demographic characteristics were collected. All patients underwent duplex ultrasound examination of their carotid vessels to obtain IMT measurements. RESULTS: One hundred and fifty-three patients (74.3%) had a carotid IMT greater than 1.0 mm at one or more point of measurement in at least one common carotid artery. There was a significant correlation between older age and mean carotid wall thickness (R=0.479 / P<0.01). Multivariate analysis identified male sex, arterial hypertension and older age as variables associated with increased IMT (P<0.05 for all variables). When IMT was compared between the two ethnic groups in this study, no significant differences were noted. Euro-descendants and Afro-descendants had similar IMT values, even when the groups were stratified by degree of IMT (normal vs. increased) and presence of stroke and/or transient ischemic attack (yes vs. no). CONCLUSIONS: The risk factors associated with increased common carotid artery IMT in Brazilian individuals are similar to those in previously described populations. No differences were observed between the two main Brazilian ethnic groups. Longitudinal studies are required for a better evaluation of the incidence, etiologic factors and evolution of carotid intimomedial thickening in this population.

Comparison of common carotid artery intima-media thickness between Brazilian Euro-descendants and Afro-descendants with atherosclerosis risk factors

OBJECTIVE: To compare common carotid intima-media thickness (IMT) between the two major Brazilian ethnic groups (those of African descent and those of European descent) among individuals with one or more risk factors for atherosclerotic disease. METHOD: Two hundred and six patients with one or more risk factors for atherosclerotic disease were evaluated in a cross-sectional study in which their clinical, ethnic and Demographic characteristics were collected. All patients underwent duplex ultrasound examination of their carotid vessels to obtain IMT measurements. RESULTS: One hundred and fifty-three patients (74.3%) had a carotid IMT greater than 1.0 mm at one or more point of measurement in at least one common carotid artery. There was a significant correlation between older age and mean carotid wall thickness (R=0.479 / P<0.01). Multivariate analysis identified male sex, arterial hypertension and older age as variables associated with increased IMT (P<0.05 for all variables). When IMT was compared between the two ethnic groups in this study, no significant differences were noted. Euro-descendants and Afro-descendants had similar IMT values, even when the groups were stratified by degree of IMT (normal vs. increased) and presence of stroke and/or transient ischemic attack (yes vs. no). CONCLUSIONS: The risk factors associated with increased common carotid artery IMT in Brazilian individuals are similar to those in previously described populations. No differences were observed between the two main Brazilian ethnic groups. Longitudinal studies are required for a better evaluation of the incidence, etiologic factors and evolution of carotid intimomedial thickening in this population.

Incidence of ipsilateral postoperative deep venous thrombosis in the amputated lower extremity of patients with peripheral obstructive arterial disease.

OBJECTIVE: Patients undergoing amputation of the lower limb due to peripheral arterial disease (PAD) are at risk of developing deep venous thrombosis (DVT). Few studies in the research literature report the incidence of DVT during the early postoperative period or the risk factors for the development of DVT in the amputation stump. This prospective study evaluated the incidence of DVT during the first 35 postoperative days in patients who had undergone amputation of the lower extremity due to PAD and its relation to comorbidities and death. METHODS: Between September 2004 and March 2006, 56 patients (29 men), with a mean age of 67.25 years, underwent 62 amputations, comprising 36 below knee amputations (BKA) and 26 above knee amputations (AKA). Echo-Doppler scanning was performed preoperatively and on postoperative days 7 and 31 (approximately). All patients received acetylsalicylic acid (100 mg daily) preoperatively and postoperatively, but none received prophylactic anticoagulation. RESULTS: DVT occurred in 25.8% of extremities with amputations (10 AKA and 6 BKA). The cumulative incidence in the 35-day postoperative period was 28% (Kaplan-Meier). There was a significant difference (P = .04) in the incidence of DVT between AKA (37.5%) and BKA (21.2%). Age >or=70 years (48.9% vs 16.8%, P = .021) was also a risk factor for DVT in the univariate analysis. Of the 16 cases, 14 (87.5%) were diagnosed during outpatient care. The time to discharge after amputation was averaged 6.11 days in-hospital stay (range, 1-56 days). One symptomatic nonfatal pulmonary embolism occurred in a patient already diagnosed with DVT. There was no relation between other comorbidities and DVT. The multivariate analysis showed no association between risk factors and the occurrence of DVT in the amputated extremity. DVT ipsilateral to the amputation did not influence the mortality rate (9.7%). CONCLUSION: The incidence of DVT in the early postoperative period (or=70 years and for AKA. Patients with PAD who have recently undergone major amputations should be considered at high risk for DVT, even after hospital discharge. Given the high rate of postoperative DVT observed in this study, we now recommend prophylactic anticoagulation for these patients, but further study is needed to determine the optimal duration and efficacy of this treatment.

A practical protocol to measure common carotid artery intima-media thickness.

OBJECTIVE: To describe and test a practical protocol to measure common carotid intima-media thickness that uses the combined values of two longitudinal examination angles to increase sensitivity. METHOD: Between February and September 2005, 206 patients underwent duplex scan examination of carotid vessels, and the intima-media thickness of 407 common carotids were measured in three angles: transversal, longitudinal posterolateral, and anterolateral, with three intima-media thickness measurements for each near and far wall. In addition to numbers obtained from the three angles of measurement, a fourth visual perspective was obtained by combining the intima-media thickness results of posterolateral and anterolateral longitudinal views and considering the thickest wall measurement. RESULTS: Two hundred seventy (66.3%) carotid arteries had an intima-media thickness thicker than 1mm. The mean intima-media thickness values achieved by the different incidences were 1.26+/-0.6 mm (transversal), 1.17+/-0.54 mm (longitudinal anterolateral), and 1.18+/-0.58 mm (longitudinal posterolateral). A significant difference in intima-media thickness measurement values was observed when the three angles of examination plus the combined positive results of both longitudinal angles were compared by ANOVA (P=0.005). The LSD Post-Hoc test determined that the combined longitudinal view results were similar to the transversal views (P=0.28) and had greater intima-media thickness means than isolated anterolateral or posterolateral longitudinal views (P=0.02 and 0.05, respectively). CONCLUSIONS: The protocol presented is a practical method for obtaining common carotid artery intima-media thickness measurements. The combined longitudinal posterolateral and anterolateral longitudinal views provide a more sensitive evaluation of the inner layers of the carotid walls than isolated longitudinal views.

A practical protocol to measure common carotid artery intima-media thickness

OBJECTIVE: To describe and test a practical protocol to measure common carotid intima-media thickness that uses the combined values of two longitudinal examination angles to increase sensitivity. METHOD: Between February and September 2005, 206 patients underwent duplex scan examination of carotid vessels, and the intima-media thickness of 407 common carotids were measured in three angles: transversal, longitudinal posterolateral, and anterolateral, with three intima-media thickness measurements for each near and far wall. In addition to numbers obtained from the three angles of measurement, a fourth visual perspective was obtained by combining the intima-media thickness results of posterolateral and anterolateral longitudinal views and considering the thickest wall measurement. RESULTS: Two hundred seventy (66.3 percent) carotid arteries had an intima-media thickness thicker than 1mm. The mean intima-media thickness values achieved by the different incidences were 1.26±0.6mm (transversal), 1.17±0.54mm (longitudinal anterolateral), and 1.18±0.58mm (longitudinal posterolateral). A significant difference in intima-media thickness measurement values was observed when the three angles of examination plus the combined positive results of both longitudinal angles were compared by ANOVA (P=0.005). The LSD Post-Hoc test determined that the combined longitudinal view results were similar to the transversal views (P=0.28) and had greater intima-media thickness means than isolated anterolateral or posterolateral longitudinal views (P=0.02 and 0.05, respectively). CONCLUSIONS: The protocol presented is a practical method for obtaining common carotid artery intima-media thickness measurements. The combined longitudinal posterolateral and anterolateral longitudinal views provide a more sensitive evaluation of the inner layers of the carotid walls than isolated longitudinal views.

Late results of catheter-directed recombinant tissue plasminogen activator fibrinolytic therapy of iliofemoral deep venous thrombosis.

PURPOSE: To evaluate the efficacy of catheter-directed low-dose recombinant tissue-type plasminogen activator infusion in the treatment of iliofemoral deep venous thrombosis and prevention of post-thrombotic syndrome. METHOD: Eighteen patients (out of 260 evaluated) with acute iliofemoral deep venous thrombosis and no previous evidence of venous insufficiency were prospectively selected for thrombolytic therapy. Catheter-directed low-dose recombinant tissue-type plasminogen activator (1 mg/h) was infused into the thrombotic segments. RESULTS: Effective fibrinolysis was achieved in 14 of 18 cases, with correlation between effective fibrinolysis and major/complete resolution of acute signs and symptoms (P <.01). There were no episodes of major complications. Four patients presented with early rethrombosis (1 to 8 weeks). Individuals were followed for a period up to 131 weeks (average, 85.2). The incidence of clinical signs and symptoms of venous insufficiency and duplex-scan findings of valvular reflux was significantly lower in the patients in which lytic therapy succeeded and patency was kept, compared with patients experiencing acute therapeutic failure or rethrombosis (P <.01). CONCLUSIONS: Low-dose recombinant tissue-type plasminogen activator fibrinolytic therapy is safe and effective in the treatment of acute iliofemoral venous thrombosis. The late evolution as revealed clinically and by ultrasound was superior in patients for whom lytic therapy was effective.

Late results of catheter-directed recombinant tissue plasminogen activator fibrinolytic therapy of iliofemoral deep venous thrombosis

PURPOSE: To evaluate the efficacy of catheter-directed low-dose recombinant tissue-type plasminogen activator infusion in the treatment of iliofemoral deep venous thrombosis and prevention of post-thrombotic syndrome. METHOD: Eighteen patients (out of 260 evaluated) with acute iliofemoral deep venous thrombosis and no previous evidence of venous insufficiency were prospectively selected for thrombolytic therapy. Catheter-directed low-dose recombinant tissue-type plasminogen activator (1 mg/h) was infused into the thrombotic segments. RESULTS: Effective fibrinolysis was achieved in 14 of 18 cases, with correlation between effective fibrinolysis and major/complete resolution of acute signs and symptoms (P <.01). There were no episodes of major complications. Four patients presented with early rethrombosis (1 to 8 weeks). Individuals were followed for a period up to 131 weeks (average, 85.2). The incidence of clinical signs and symptoms of venous insufficiency and duplex-scan findings of valvular reflux was significantly lower in the patients in which lytic therapy succeeded and patency was kept, compared with patients experiencing acute therapeutic failure or rethrombosis (P <.01). CONCLUSIONS: Low-dose recombinant tissue-type plasminogen activator fibrinolytic therapy is safe and effective in the treatment of acute iliofemoral venous thrombosis. The late evolution as revealed clinically and by ultrasound was superior in patients for whom lytic therapy was effective.

OBJETIVOS: Avaliar a eficácia da infusão seletiva por cateter do ativador de plasminogênio tecidual recombinante em baixas doses no tratamento da trombose venosa iliacofemoral e na prevenção da síndrome pós-trombótica. MÉTODO: Dezoito pacientes (de 260 avaliados) portadores de trombose venosa profunda iliacofemoral sem evidência prévia de insuficiência venosa foram selecionados para terapia fibrinolítica e submetidos a infusão seletiva por cateter do ativador de plasminogênio tecidual recombinante na dose de 1mg/dl nos segmentos venosos trombóticos. RESULTADOS: Quatorze pacientes apresentaram fibrinólise efetiva; observamos correlação entre o grau de melhora clínica observado e a redução percentual do volume trombótico (P<.01). Não houve episódios de complicações graves. Quatro pacientes apresentaram retrombose precoce (1 a 8 semanas). Os pacientes foram seguidos por um período de até 131 semanas (média 85.2). A incidência de sinais e sintomas clínicos de insuficiência venosa e os achados ecográficos de refluxo valvular foram significativamente menores nos pacientes em que a terapia fibrinolítica foi efetiva e a perviedade mantida ao longo do período de seguimento, na comparação com os casos de falha aguda ou de retrombose precoce (P<.01). CONCLUSÕES: A terapia fibrinolítica da trombose venosa iliacofemoral com ativador de plasminogênio tecidual recombinante seletivo em baixas doses demonstrou-se eficaz e segura. A evolução clínica e ecográfica tardia foi superior nos pacientes em que a terapia lítica foi efetiva.

Doença arterial obstrutiva periférica: que atenção temos dispensado à abordagem clínica dos pacientes? / Peripheral obstructive arterial disease: what kind of clinical treatment are we recommending to our patients?

OBJETIVO: Avaliar como pacientes com doença arterial obstrutiva periférica têm sido tratados, em nosso meio, com relação aos fatores de risco e comorbidades. MÉTODO: Questionário sobre pesquisa e tratamento da dislipidemia, diabetes, exercício, uso de anti-plaquetários, tabagismo e hipertensão arterial no paciente com doença arterial obstrutiva periférica foi aplicado entre os médicos presentes na reunião mensal de março de 2004 da Sociedade Brasileira de Angiologia e Cirurgia Vascular - Regional São Paulo. RESULTADOS: Dos 102 questionários distribuídos, 75 foram respondidos (taxa de resposta de 73,5 por cento). Entre os consultados, 82 por cento pesquisam rotineiramente perfil lipídico e 20 por cento visam alvo de LDL-colesterol abaixo de 100 mg/dl; 94 por cento realizam pesquisa para diabetes melito; 97 por cento recomendam exercício; 79 por cento prescrevem aspirina; 97 por cento aconselham que os pacientes parem de fumar e 60 por cento se restringem ao aconselhamento isoladamente; 18 por cento não realizam a medida da pressão arterial durante a consulta e 19 por cento visam alvo pressórico de 130 x 80 mmHg. Considerando todas as avaliações em conjunto - intervenção no estilo de vida, no sentido de parar de fumar, orientação de exercícios, uso de anti-plaquetários, realização de pesquisa para diabetes melito, controle rigoroso da pressão arterial e lípides - observou-se que 7 por cento dos entrevistados seguem todas essas recomendações como uma rotina estabelecida. CONCLUSÃO: O presente estudo demonstrou que, em nosso meio, a pesquisa e o tratamento dos fatores de risco e comorbidades nos pacientes com doença arterial obstrutiva periférica estão sendo sub-realizados.

OBJECTIVE: The purpose of this survey was to evaluate how patients with peripheral obstructive arterial disease have been treated, concerning risk factors and comorbidities. METHOD: A questionnaire was applied to all physicians attending the monthly meeting of the Brazilian Society of Angiology and Vascular Surgery - São Paulo Section. Questions were asked about the following major risk factors: treatment of dyslipidemia, diabetes, exercise regimens, antiplatelet therapy, smoking and arterial hypertension. RESULTS: Of the 102 questionnaires, 75 were answered (response rate of 73.5 percent). Of these, 82 percent routinely measure cholesterol levels and 20 percent aim at an LDL cholesterol target below 100 mg/dl; 94 percent perform a screening for diabetes mellitus; 97 percent recommend patients to an exercise program; 79 percent prescribe aspirin; 97 percent recommend patients to quit smoking and 60 percent only do it by counseling; 18 percent do not measure blood pressure and 19 percent have a target pressure of 130 x 80 mmHg. Considering the recommendations as a whole - lifestyle intervention in order to quit smoking, aerobic exercise, prescription of antiplatelet therapy, screening for diabetes mellitus, rigorous control of blood pressure and lipids - it was observed that 7 percent of interviewees follow all of them as an established routine. CONCLUSION: The present study showed that patients with peripheral arterial disease are currently undertreated with regard to the screening and treatment of risk factors and comorbidities.