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.

Guidelines for superficial venous thrombosis.

Superficial venous thrombosis (SVT) or superficial thrombophlebitis is characterized by thrombi within superficial veins, with partial involvement or occlusion of the lumen and inflammatory reaction along the course of the vein. Clinical diagnosis tends to be straightforward, but supplementary tests and examinations are needed to confirm thrombosis extension and possible thromboembolic complications. SVT can be associated with deep venous thrombosis in 6 to 40% of cases, with asymptomatic pulmonary embolism (PE) in 20 to 33%, and with symptomatic PE in 2 to 13%. Despite the morbidity and complications, there are currently no Brazilian guidelines for SVT. These guidelines cover the most important issues related to SVT definition, terminology, and etiology, and set out recommendations for diagnosis and treatment.

Biomechanical and histologic analysis in aortic endoprosthesis using fibrin glue.

BACKGROUND: The absence of incorporation between endoprosthesis (EP) and the arterial wall may lead to device migration and endoleaks around the stent graft. Alternatives have been tested aiming to improve this incorporation. Fibrin glue is used in many operating procedures promoting adhesion and tissue regeneration; however, its use to improve EP incorporation by arteries is unknown. OBJECTIVE: The objective of this study was to analyze dislodgement forces needed to extract the EPs implanted in pig aorta, compare different oversizing and fibrin glue injections, and to analyze histologic changes among groups. METHODS: Straight EPs were implanted in the thoracic aorta of pigs using 10% oversizing plus fibrin glue in the interface between the EP and the artery (group 1), using 20% oversizing (group 2), and 10% oversizing (group 3). Fourteen days after the implant, the animals were killed to enable biomechanical analysis of the EP and to verify histologic changes of the aortic wall and its interface with the EP. RESULTS: Group 1 showed a dislodgement force of 21.9 ± 5.3 Newton (N) being higher than the other groups and statistically significant when compared to group 3 (15.6 ± 3.6N), P = .003%. Group 2 had a higher dislodgement force and statistically more significant than group 3 (19.5 ± 7.8N). Histologic analysis showed tissue reaction with inflammatory cells and fibroblasts higher in group 1 and group 2 compared to group 3. CONCLUSION: This study reports a large animal survival model of thoracic aortic stent graft placement by testing the impact of fibrin glue on EP incorporation. Compared to oversizing alone, fibrin glue placed between the stent graft and the arterial wall increases EP incorporation. Additional studies are needed to determine the potential utility of fibrin glue in the setting of human arterial endografts.

An Observational Registry of Carotid Endarterectomy and Carotid Artery Stenting in Brazil: Study Protocol.

BACKGROUND: Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. CEA has been considered the first-line treatment for carotid stenosis worldwide, and the safety and efficacy of CAS compared to CEA remains in question. OBJECTIVE: The purpose of this study is to compare the practice and outcomes of CAS and CEA in a real-world setting within public university hospitals in Brazil. METHODS: This study will be a prospective 5-year analysis of treatment for atherosclerotic carotid stenosis with CEA and CAS performed at 5 centers affiliated with the Vascular Study Group at public university hospitals in Brazil. The indications for the procedures will be determined by each surgeon's individual discretion, in accordance with preoperative risk evaluation. The primary outcome measures will be (1) any in-hospital stroke or death, and (2) any per-procedural stroke, death, or myocardial infarction (MI). Patients undergoing CEA in conjunction with cardiac surgery will be excluded from the study. Multivariate logistic regression will be performed to identify predictors of stroke or death in patients undergoing CEA and CAS. All tests of significance will be performed at the .05 level. This study was approved by the Committee of Ethics in Research at the University Hospital of Ribeirao Preto Medical School, and in all other participating institutions linked to National Research System and National Board of Health in Brazil (Process 15695/2011). RESULTS: This study is currently in the recruitment phase, and the final patient is expected to be enrolled by the end of 2018. We hope to recruit approximately 800 patients to the study. Analyses will focus on primary end points for patients that are allocated to each treatment group. During the per-procedural period, the occurrence of the primary end point components (stroke, MI, or death) for CAS and CEA will be analyzed for symptomatic or asymptomatic subjects. CONCLUSIONS: The analyses of the primary endpoints (and all others variables of the study) are expected to be published in 2019 in a peer reviewed journal, and results will be presented at scientific meetings, with summary results published online. This study will obtain new data related to the quality of treatment for carotid disease in Brazil at the primary training centers of future vascular surgeons, but the initial data that will be obtained and published (with the outcomes and complications) are restricted to the first 30 days postprocedure. This time restriction limits the comparison of the results that relate to the main goal of treatment, which is to decrease the risk of stroke over 5 years. The purpose of the study group is to continue the monitoring of patient records, and evaluate the follow-up data in the 5 years following the initial evaluation. This study protocol will contribute very significantly to improving the care of patients with carotid disease, in addition to qualifying the level of assistance provided in public university hospitals in the state of São Paulo, Brazil. TRIAL REGISTRATION: Clinicaltrials.gov NCT02538276; https://www.clinicaltrials.gov/ct2/show/NCT02538276 (Archived by WebCite at http://www.webcitation.org/6m7APnFLD).

[Popliteal artery entrapment syndrome].

The popliteal artery entrapment syndrome is characterized by extrinsic compression of this artery as a result of anatomic deviation from its usual course, or by compression from musculotendinous structures in the popliteal fossa. Clinical symptoms appear when these affected individuals do strenuous exercises. There are two types of popliteal artery entrapment syndrome: the classicalor congenital form, and the functional or acquired form. In the classical form, disturbances in the embryogenesis lead either directy to popliteal artery anomalies or to alterations of adjacent structures that cause compression of the popliteal artery. In the functional form, hypertrophy of the gastrocnemius muscle secondary to exercise has been postulated as a cause. In both types, diagnosis is made through the detection of total occlusion or important stenosis of the popliteal artery. This is identified by duplex scan, magnetic resonance or arteriography during active plantar flexion-extension. A positive test in non-symptomatic subjects presenting no anatomical anomalies led to discussions about its specificity. This study presents a review of anatomical and functional popliteal artery entrapment syndrome and discusses accuracy, sensitivity and specificity of the diagnostic tests.

Aneurisma da artéria carótida interna / Aneurysm of the internal carotid artery

Os aneurismas de artéria carótida interna (ACI) extracraniana são raros. Há poucos relatos na literatura médica quanto à sua etiologia, relacionando-os à doença aterosclerótica, às arterites e alterações decorrentes do trauma ou após procedimento cirúrgico. A história natural da doença ainda não está bem estabelecida. Entretanto, o potencial risco de embolia originário do aneurisma ou mesmo de sua ruptura indica necessidade de intervenção. Apresentamos o relato de caso de uma mulher de 71 anos diagnosticada com aneurisma de 3 cm de diâmetro da ACI extracraniana direita com queixas de cefaleia pulsátil. Após tentativa sem sucesso de tratamento endovascular, optou-se pelo tratamento cirúrgico com aneurismectomia e anastomose primária término-terminal próximo à base do crânio.

Aneurysms of the extracranial internalcarotid artery are rare. There are few reports in the medical literature about the etiology of this disease, relating it to atherosclerosis, arteritis and alterations due to trauma or after a surgical procedure. The natural history of this disease has not been defined. However, the potential risk of embolism or rupture creates a need for intervention. We will present the case of a 71 year old woman with pulsatile headaches who was diagnosed a 3 cm aneurysm of the right extracranial internal carotid artery. After an unsuccessful attempt at endovascular treatment, we performed an aneurysmectomy and primary arterial anastomosis near the cranium base.

Fatores envolvidos na migração das endopróteses em pacientes submetidos ao tratamento endovascular do aneurisma da aorta abdominal / Factors involved in the migration of endoprosthesis in patients undergoing endovascular aneurysm repair

A migração da endoprótese é complicação do tratamento endovascular definida como deslocamento da ancoragem inicial. Para avaliação da migração, verifica-se a posição da endoprótese em relação a determinada região anatômica. Considerando o aneurisma da aorta abdominal infrarrenal, a área proximal de referência consiste na origem da artéria renal mais baixa e, na região distal, situa-se nas artérias ilíacas internas. Os pacientes deverão ser monitorizados por longos períodos, a fim de serem identificadas migrações, visto que estas ocorrem normalmente após 2 anos de implante. Para evitar migrações, forças mecânicas que propiciam fixação, determinadas por características dos dispositivos e incorporação da endoprótese, devem predominar sobre forças gravitacionais e hemodinâmicas que tendem a arrastar a prótese no sentido caudal. Angulação, extensão e diâmetro do colo, além da medida transversa do saco aneurismático, são importantes aspectos morfológicos do aneurisma relacionados à migração. Com relação à técnica, não se recomenda implante de endopróteses com sobredimensionamento excessivo (> 30 por cento), por provocar dilatação do colo do aneurisma, além de dobras e vazamentos proximais que também contribuem para a migração. Por outro lado, endopróteses com mecanismos adicionais de fixação (ganchos, farpas e fixação suprarrenal) parecem apresentar menos migrações. O processo de incorporação das endopróteses ocorre parcialmente e parece não ser suficiente para impedir migrações tardias. Nesse sentido, estudos experimentais com endopróteses de maior porosidade e uso de substâncias que permitam maior fibroplasia e aderência da prótese à artéria vêm sendo realizados e parecem ser promissores. Esses aspectos serão discutidos nesta revisão.

Migration of the endoprosthesis is defined as the misplacement of its initial fixation. To assess the migration, the position of the endoprosthesis regarding a certain anatomic region is verified. Considering the aneurysm of the infrarenal abdominal aorta, the proximal area of reference is the origin of the lowest renal artery and, at the distal region, it is located next to the internal iliac arteries. Patients should be monitored for long periods so that migrations can be identified; these migrations usually occur 2 years after the implantation. To avoid migrations, mechanical forces that enable fixation and that are determined by the characteristics of the devices and by the incorporation of the endoprosthesis should predominate over gravitational and hemodynamic forces, which tend to drag the prosthesis toward to caudal direction. Angulation, extension, and diameter of the neck, and transversal measure of the aneurysmatic sac are important morphological aspects related to migration. In relation to the technique, endoprosthesis implantation with excessive oversizing (> 30 percent) is not recommended because it leads to aortic neck dilatation, folds and proximal leakage that also contribute to migration. On the other hand, endoprosthesis with additional fixation devices (hooks, barbs and suprarenal fixation) seem to be less associated with migration. The process of endoprosthesis incorporation is partial and does not seem to be enough to prevent later migrations. In this sense, experimental studies with endoprosthesis of higher porosity, as well as the use of substances that allow higher fibroplasia and adherence of the prosthesis to the artery, have been conducted and are promising. Such aspects are discussed in the present review of the literature.

Síndrome do aprisionamento da artéria poplítea / Popliteal artery entrapment syndrome

A síndrome do aprisionamento da artéria poplítea é uma doença caracterizada pela compressão extrínseca dessa artéria, causada pelo desvio de seu trajeto anatômico habitual ou por estruturas musculotendinosas da fossa poplítea. Os sintomas clínicos costumam aparecer quando os indivíduos realizam esforços físicos. Distinguem-se dois tipos de síndrome do aprisionamento da artéria poplítea: a clássica ou congênita e a funcional ou adquirida. Na forma clássica, distúrbios do desenvolvimento embrionário provocam anomalias no trajeto da artéria poplítea ou de estruturas adjacentes que ocasionam a compressão. Na forma funcional ou adquirida, identifica-se apenas hipertrofia dos músculos gastrocnêmios como possível causa do encarceramento. O diagnóstico, em ambos os tipos, é feito pela detecção de oclusão ou estenose significativa da artéria poplítea às manobras de dorsiflexão e hiperextensão ativa dos pés, utilizando-se mapeamento dúplex, ressonância magnética ou arteriografia.A identificação desses testes positivos em indivíduos assintomáticos e sem alterações anatômicas trouxe questionamento a respeito da especialidade dos testes diagnósticos.Este trabalho apresenta uma revisão da síndrome do aprisionamento da artéria poplítea anatômica e funcional, além de discutir acurácia, sensibilidade e especialidade dos testes diagnósticos em cada caso.

Síndrome compartimental crônica de membros inferiores / Chronic compartment syndrome of the lower limbs

A síndrome compartimental crônica é uma afecção pouco comum e pouco diagnosticada, caracterizada por distúrbios dolorosos dos membros inferiores, causados por aumenro da pressão intracompartimental após exercícios físicos. Fatores anatômicos, tais como tamanho restrito do compartimento, aumento do volume intracompartimental, fascia constritiva, perda da elasticidade do compartimento, alteração do retorno venoso ou aumento da massa muscular, podem contribuir para seu aparecimento. O diagnóstico deve ser suspeitado nos casos de dor localizada nas lojas anteriores ou posteriores das pernas após exercícios físicos e deve ser confirmado por registro de aumento da pressão intracompartimental em repouso e após exercícios. O diagnóstico diferencial deve ser feito com claudicação intermitente, aprisionamento da artéria poplítea, miosites, tendinites, periostires, fraturas, neuropatias, insuficiência cardíaca congestiva [confirmar com autores]. O tratamento inicial consiste na modificação das atividades físicas e, diante de sintomas refratários ou necessidade de manutenção das atividades, o tratamento definitivo é a fasciectomia. Neste artigo, é apresentado um caso típico de síndrome compartimental crônica tratado cirurgicamente com sucesso, sendo discutida a fisio patologia, o diagnóstico e as indicações de cirurgia. Palavras-chave: síndrome do compartimento anterior, doença crônica, claudicação intermitente, membros inferiores.