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.

National Cross-Sectional Epidemiological Analysis of the Impact of Pandemic COVID-19 on Vascular Procedures in Public Health System: 521,069 Procedures Over 4 Years.

BACKGROUND: During the COVID-19 pandemic, there was a dramatic increase in healthcare demand. Resources were redirected to care patients with COVID-19. Therefore, surgical treatments were affected, including those of vascular diseases. There are no studies evaluating the whole impact of the COVID-19 pandemic, considering all types of vascular procedures, both elective and urgent, in a large country. The aim of the present study was to analyze the impact on all types of vascular procedures performed in Brazilian public hospitals during the COVID-19 pandemic. METHODS: Cross-sectional population-based analysis of publicly available data referring to vascular procedures. Surgeries 2 years before the pandemic onset (2018-2019) and 2 years during pandemic (2020-2021) were included. RESULTS: We observed a total of 521,069 procedures. Decrease was observed in elective abdominal aortic aneurysm repairs both open surgery (P = 0.001) and endovascular surgery (P < 0.001), emergency open abdominal repairs (P = 0.005), elective thoracic aortic aneurysm repairs (P = 0.007), elective open peripheral aneurysm repairs (P = 0.038), carotid endarterectomies (P < 0.001) and angioplasties (P = 0.001), open revascularizations for peripheral arterial disease (P < 0.001), surgical treatment of chronic venous disease (P < 0.001) and sympathectomies for hyperhidrosis (P < 0.001). However, there was an increase of lower limb amputations (P = 0.027) and vena cava filter placements (P = 0.005). There was a reduction of almost US$17 million in financial investments. CONCLUSIONS: The reorganization of health systems led to a significant reduction in vascular procedures and decrease in financial investments. On the other hand, there was a significant increase in the number of lower limb amputations and vena cava filter placements.

Nationwide Cross-sectional Analysis of Endoscopic Thoracic Sympathectomy to Treat Hyperhidrosis Over 12 years in Brazil: Epidemiology, Costs, and Mortality.

OBJECTIVE: To analyze the number of endoscopic thoracic sympathectomies performed to treat hyperhidrosis in the Universal Public Health System of Brazil, the government reimbursements, and the in-hospital mortality rates. BACKGROUND: Even though endoscopic thoracic sympathectomy has been widely performed for the definitive treatment of hyperhidrosis, no series reported mortality and there are no population-based studies evaluating its costs or its mortality rate. METHODS: Data referring to endoscopic thoracic sympathectomy to treat hyperhidrosis between 2008 and 2019 were extracted from the database of the Brazilian Public Health System, which insures more than 160 million inhabitants. RESULTS: Thirteen thousand two hundred one endoscopic thoracic sympathectomies to treat hyperhidrosis were performed from 2008 to 2019, with a rate of 68.44 procedures per 10 million inhabitants per year. There were 6 in-hospital deaths during the whole period, representing a mortality rate of 0.045%. The total expended throughout the years was U$ 6,767,825.14, with an average of U$ 512.68 per patient. CONCLUSIONS: We observed a rate of 68.44 thoracoscopic sympathectomies for hyperhidrosis' treatment per 10 million inhabitants per year. The inhospital mortality rate was very low, 0.045%, though not nil. To our knowledge, no published series is larger than ours and we are the first authors to formally report deaths after endoscopic thoracic sympathectomies to treat hyperhidrosis. Moreover, there is no other population-based study addressing costs and mortality rates of every endoscopic thoracic sympathectomy for the treatment of any site of hyperhidrosis in a given period.

Radiological Profile of 18,430 Vascular Anomalies: Incidence and Demographic Distribution in an Adult Population.

BACKGROUND: Most studies on focusing on the prevalence of vascular anomalies are either aimed to determine the individual occurrence of a specific type among known bearers of abnormalities or propose an estimation of prevalence for the general population by extrapolating from the paediatric population. In this scenario, we intended to assess the profile of vascular anomalies in a group of patients subjected to imaging studies, throughout a long period of time, to evaluate the frequency of abnormal findings in a consecutive, nonselected population. METHODS: This is a retrospective review of 996,569 computed tomography and magnetic resonance studies between 2009 and 2019. Findings were grouped as vascular tumours (hemangiomas; vascular tumours), cavernomas, and vascular malformations. Positive findings were evaluated with regard to patients' demographic characteristics and anatomic distribution and the subset of vascular malformations was also evaluated with regard to size, classification in accordance to flow pattern, and Hamburg Classification. RESULTS: Eighteen thousand four hundred thirty positive examinations were evaluated (mean age, 55.82 ± 15.43 years; 8,188 men). Vascular anomalies were present in 18.49 per 1,000 examinations (17.41 hemangiomas; 0.69 cavernomas and 0.39 vascular malformations per 1,000 examinations). Hemangiomas and cavernomas were homogeneous in anatomic location between sexes throughout the age groups. Complex malformations were heterogeneous in anatomic distribution between the sexes in each age group, with intracranial findings decreasing for female patients in older groups. CONCLUSIONS: Vascular anomalies were found in 18.49 per 1,000 examinations. Hemangiomas and cavernomas were homogenously distributed, whereas complex malformations displayed a heterogeneous anatomic distribution pattern between sexes in each age group.

Epidemiology of the use of inferior vena cava filters in Brazil between 2008 and 2019.

OBJECTIVES: The primary objective was to study the totality of inferior vena cava filter placements and their temporal and geographic distribution in the Brazilian Public Health System, which insures more than 160 million Brazilians. The secondary objective was to analyze in-hospital mortality after filter placement and deaths due to pulmonary embolism. METHODS: Public and open data on in-hospital mortality due to pulmonary embolism and on rates of inferior vena cava filters placement, its associated diagnosis, and in-hospital mortality in Brazilian public hospitals between January 2008 and December 2019 were extracted from Ministry of Health databases. RESULTS: A total of 9108 inferior vena cava filters were placed, 98.18% of which was therapeutic. We observed a significant increase in the use of these devices over the years, from 508 inferior vena cava filters placed in 2008 to 965 in 2019. In-hospital mortality rate in patients who received inferior vena cava filters was 6.21%, stable over time, and 96.64% of causes of these causes were attributed to venous thromboembolism. The in-hospital mortality rate due to pulmonary embolism, regardless of the placement of vena cava filters, has increased significantly. CONCLUSION: We observed a low but increasing rate of inferior vena cava filter placements in Brazil between 2008 and 2019, most indications were therapeutic. Our findings were heterogeneous across Brazilian regions and contrasted to those observed in the USA, which is likely due to cultural and socioeconomic factors.

The impact of the institutional abdominoperineal resections volume on short-term outcomes and expenses: a nationwide study.

BACKGROUND: The aim of this study was to evaluate the influence of the institutional volume of abdominoperineal resections (APR) on the short-term outcomes and costs in the Brazilian Public Health system. METHODS: This population-based study evaluated the number of APRs by institutions performed in the Brazilian Public Health system from January/2010 to July/2022. Data were extracted from a public domain from the Brazilian Public Health system. RESULTS: Four hundred and twelve hospitals performed APRs and were included. Only 23 performed at least 5 APRs per year on average and were considered high-volume institutions. The linear regression model showed that the number of hospital admissions for APRs was negatively associated with in-hospital mortality (Coef. = - 0.001; p = 0.013) and length of stay in the intensive care unit (Coef. = - 0.006; p = 0.01). The number of hospital admissions was not significantly associated with personnel, hospital, and total costs. The in-hospital mortality in high-volume institutions was significantly lower than in low-volume institutions (2.5 vs. 5.9%; p: < 0.001). The mean length of stay in the intensive care unit was shorter in high-volume institutions (1.23 vs. 1.79 days; p = 0.021). In high-volume institutions, the personnel (R$ 952.23 [US$ 186.64] vs. R$ 11,129.04 [US$ 221.29]; p = 0.305), hospital (R$ 4078.39 [US$ 799.36] vs. R$ 4987.39 [US$ 977.53]; p = 0.111), and total costs (R$ 5030.63 [US$ 986.00] vs. R$ 6116.71 [US$ 1198.88]; p = 0.226) were lower. CONCLUSIONS: Higher institutional APR volume is associated with lower in-hospital mortality and less demand for intensive care. The findings of this nationwide study may affect how Public Health manages APR care.

Cross-Sectional Analysis of 180,595 Lower Limb Amputations in the State of Sao Paulo Over 12 Years.

BACKGROUND: Lower limb amputations represent a high social, economic and health burden. Most of them are preventable and reflect areas for improvement in health care, making it essential to know their epidemiology. MATERIALS AND METHODS: This is a retrospective population-based cross-sectional analysis on all lower limb amputations performed in public hospitals in Sao Paulo between 2009 and 2020, the most populous Brazilian state, with 46 million inhabitants. Using a public database, we evaluated types, rates and trends of the amputations performed, main etiologies leading to the indication for amputation, hospital length of stay and in-hospital mortality rates, demographics of the amputees and procedure costs. RESULTS: In total, 180,595 lower limb amputations and surgical revision of amputations were performed, with toe amputations (45%) and major amputations (33%) being the most frequent types of surgeries, with a recent significant increase in the rates for both these procedures. Peripheral artery disease was the most frequent etiology, followed by diabetes mellitus, with both showing an upward trend over the years. Most patients were male (69.3%), Caucasians (55.6%) and elderly. August was the month with the highest number of amputations in all years. Overall in-hospital mortality after lower limb amputations was 6.6%. Total reimbursed by the government was US$ 67,675,875.55. CONCLUSIONS: Peripheral artery disease is the most frequent underlying diagnosis for lower limb amputations, followed by diabetes mellitus, with both showing an upward trend over the years. We observed seasonality in procedure rates, with peaks in August in all years.

Epidemiology of Abdominal Aortic Aneurysm Repair in Brazil from 2008 to 2019 and Comprehensive Review of Nationwide Statistics Across the World.

INTRODUCTION: Studying epidemiology of abdominal aortic aneurysms repairs is essential to prevent related deaths. Although outcomes are influenced by socioeconomic factors, there are no nationwide studies on these statistics in low-and-middle income countries. Therefore, we designed this study to evaluate abdominal aortic aneurysms repair rates, trends, costs, and in-hospital mortality in the Brazilian Public Health System, which exclusively insures over 160 million Brazilians. MATERIAL AND METHODS: Retrospective cross-sectional population-based analysis of publicly available data referring to all abdominal aortic aneurysm repairs performed between 2008 and 2019 in Brazilian public hospitals. RESULTS: We observed a total of 13,506 abdominal aortic aneurysm repairs, of which 32% were emergency endovascular repairs, 20% emergency open repairs, 32% elective endovascular repairs and 16% elective open repairs. There has been a downward trend in total abdominal aortic aneurysms repairs and an increasing predominance of endovascular repair. Elective and endovascular repairs were significantly associated with lower in-hospital mortality. For ruptured abdominal aortic aneurysms, we observed mortality rates of 13.8% after endovascular repair and 52.1% after open repair. For intact abdominal aortic aneurysms, we observed mortalities of 3.8% after endovascular repair and 18.6% after open repair. Procedure and mortality rates varied significantly among the Brazilian regions. CONCLUSIONS: We observed a low and decreasing rate of abdominal aortic aneurysm repair. Most repairs were emergency and endovascular and there was an increasing predominance of endovascular repair. Endovascular and elective repairs were associated with lower mortality.

Nationwide Cross-Sectional Epidemiological Analysis of 3,306 Lower Limb Peripheral Aneurysm Repairs in Brazilian Public Hospitals Between 2008 and 2019: Trends, Mortality and Costs.

BACKGROUND: Although peripheral aneurysms can be limb- or life-threatening, the literature is scarce and there are only two large population-based epidemiological studies on peripheral aneurysm repair, comprising data from high-income countries only. METHODS: This is a retrospective cross-sectional analysis on open and endovascular peripheral aneurysm repairs performed between 2008 and 2019 in the Brazilian Public Health System, which exclusively insures more than 160 million Brazilians. RESULTS: A total of 3,306 peripheral aneurysm repairs were observed. Most patients were elderly (57.74%) and male (72.66%), and patients treated with endovascular repair were older (P = 0.008). Most repairs were emergency (59.56%) and open (93.8%), and there was an overall downward trend in procedure rates. We observed a decreasing predominance of emergency open repair over elective open repair (P < 0.001), but open repairs prevailed over endovascular procedures, with no tendency to change this predominance. Mortality rates were 3.12% and 3.67% after elective and emergency open repair, respectively, with no difference, and 0 and 4.24% for elective and emergency endovascular repair, respectively. The government reimbursed an average of $1170.05 for open PA repair and $1802.01 for endovascular repair. CONCLUSIONS: We presented the largest series of the literature analyzing all 3,306 lower limb peripheral aneurysm repairs performed in public hospitals in a middle-income country. Procedure rates tended to decrease. Open repair predominated. Mortality rates ranged from 0 to 4%. Most procedures were emergency, but there was a relative increase of elective treatments over the years.

Epidemiology of 869,220 varicose vein surgeries over 12 years in Brazil: trends, costs and mortality rate.

BACKGROUND: Varicose vein surgeries are the most commonly performed vascular procedure to treat the most prevalent vascular disease, chronic venous disease. However, nationwide studies on the epidemiology of varicose vein surgeries are scarce, none in developing countries. Therefore, we designed this study to assess the total number of varicose vein surgeries performed between 2008 and 2019 in the Public Health System, which exclusively insures more than 160 million Brazilians, their trends, costs and mortality rates. METHODS: Public and open data referring to all surgeries to treat chronic venous disease between 2008 and 2019 were extracted from the Brazilian Ministry of Health database. RESULTS: A total of 869,220 surgeries were performed to treat chronic venous disease in Brazilian public hospitals and outpatient clinics, with an average rate of 4.5 surgeries per 10,000 inhabitants per year. Starting in 2015, we observed a slight non-significant downward trend in the total number of procedures. The total amount reimbursed by the government was US$ 232,775,518.11. A total of 49 deaths were reported after varicose vein surgery, corresponding to a mortality rate of 0.0056%. CONCLUSIONS: A total of 869,220 surgeries were performed to treat chronic venous disease over twelve years, with an overall rate of 4.52 procedures per 10,000 population per year. The mortality rate was very low, 0.0056%.

Conventional Varicose Vein Surgery: Comparison between Single versus Staged Surgery Using Patient Reported Outcomes.

BACKGROUND: In the Brazilian public health system, conventional surgery is the standard procedure for treatment of varicose veins (VV). We aimed to compare clinical and quality of life (QoL) results of patients subjected to bilateral treatment of VV by a single-procedure or staged-procedure approach. METHODS: A total of 111 patients undergoing bilateral treatment for VV were treated either by a single-surgery or 2 staged procedures (minimal: 30-day interval) depending on institutional protocol. Patients were evaluated with respect to clinical symptoms and quality of life markers before and after treatment, by use of the VEINES-Sym/QoL and EQ5D-5L scores, and these results were then compared between groups. RESULTS: QoL scores improved in general after treatment. VV specific symptoms and QoL aspects improved equally between the Staged-procedure and Single-surgery groups (VEINES-Sym mean variation 29.7 ± 2.1 vs. 29.9 ± 2.7, respectively; P = 0.340 and VEINES-QoL mean variation 5.5 ± 3.4 vs. 4.5 ± 4.3, respectively; P = 0.369). General QoL, however, showed more improvement in the Staged-procedure than the Single-surgery group (EQD5-5L mean increase 0.1678 ± 0.1555 and 0.0785 ± 0.1384, respectively; P = 0.007). When propensity matched, patient subgroups maintained this same differences in QoL results. CONCLUSIONS: Our findings suggest that the both the Staged- and Single-surgery approach for VV surgical treatment incur similar improvement in disease-specific QoL, and that the Staged-approach may impose less of a burden in the patients' recovery.

Temporal trends in vena cava filter implantation in public health system inpatients: an 11-year analysis of the largest city in Brazil.

Background: Vena cava filter implantation is considered a simple procedure, which can lead to overuse and over-indication. It is nevertheless associated with short and long-term complications. Objectives: The goals of this study were to evaluate rates of vena cava filter implantation conducted by Brazil's Unified Public Health System, analyzing in-hospital mortality and migration of patients from other cities seeking medical attention in São Paulo. Methods: This study analyzed all vena cava filter procedures conducted from 2008 to 2018 in the city of São Paulo and registered on the public database using a big data system to conduct web scraping of publicly available databases. Results: A total of 1324 vena cava filter implantations were analyzed. 60.5% of the patients were female; 61.7% were under 65 years old; 34.07% had registered addresses in other cities or states; and there was a 7.4% in-hospital mortality rate. Conclusions: We observed an increase in the rates of use of vena cava filters up to 2010 and a decrease in rates from that year onwards, which coincides with the year that the Food and Drug Administration published a recommendation to better evaluate vena cava filter indications.

Contexto: O implante de filtro de veia cava é considerado um procedimento de baixa complexidade, o que pode resultar em indicação excessiva. No entanto, não é isento de complicações a curto e longo prazo. Objetivos: Avaliar as taxas de implantes de filtro de veia cava realizados pelo Sistema Único de Saúde e a origem geográfica e mortalidade intra-hospitalar dos pacientes. Métodos: Foi conduzida uma análise em um banco de dados públicos referente às taxas de implantes de filtro de veia cava realizados de 2008 a 2018 na cidade de São Paulo, utilizando o sistema de big data. Resultados: Foram analisados 1.324 implantes de filtro de veia cava financiados pelo Sistema Único de Saúde. Identificou-se tendência de aumento da taxa de implantação até 2010 e de redução dos números após esse período. Do total de pacientes, 60,5% eram do sexo feminino; 61,75% tinham menos de 65 anos; e 34,07% possuíam endereço oficial em outra cidade ou estado. A taxa de mortalidade intra-hospitalar foi de 7,4%. Conclusões: Observamos aumento das taxas de implante de filtro de veia cava até 2010 e redução das taxas após esse período, o que coincide com o ano em que a organização norte-americana Food and Drug Administration publicou uma recomendação para melhor avaliar as indicações de filtros.

Surgical repair of abdominal aortic aneurysms on the public health system in the largest city in Brazil: a descriptive analysis of in-hospital data on 2693 procedures over 10 years.

Background: From 1990 to 2015, mortality from aortic aneurysms increased 16.8% in Brazil. São Paulo is the largest city in Brazil and about 5 million people depend on the public health system there. Objectives: To conduct an epidemiological analysis of abdominal aortic aneurysm surgeries in the city of São Paulo. Methods: Infra-renal aortic aneurysm procedures performed over a decade (from 2008 to 2017) were studied using publicly-available platforms from the Unified Health System and DATASUS. Results: 2693 procedures were analyzed; 66.73% were endovascular; 78.7% of patients were male; 70.7% were aged 65 years or more; 64.02% were elective hospital admissions. There were 288 in-hospital deaths (mortality: 10.69%). In-hospital mortality was lower for endovascular surgery than for open surgery; both for elective (4.13% versus 14.42%) and urgent (9.73% versus 27.94%) (p = 0.019) admissions. The highest volume hospital (n = 635) had the lowest in-hospital mortality (3.31%). USD 24,835,604.84 was paid; an average of $ 2,318.63 for elective open, $ 3,420.10 for emergency open, $ 12,157.35 for elective endovascular and $ 12,969.12 for urgent endovascular procedures. Endovascular procedure costs were statistically higher than the values paid for open surgeries (p <0.001). Conclusions: Endovascular surgeries were performed twice as often as open surgeries; they had shorter hospital stays and lower mortality.

Contexto: No Brasil, a mortalidade por aneurisma de aorta aumentou 16,8% de 1990 a 2015. São Paulo é a maior cidade do Brasil, e cerca de 5 milhões de pessoas dependem do sistema público de saúde. Objetivos: Análise epidemiológica das cirurgias do aneurisma de aorta abdominal na cidade de São Paulo. Métodos: As cirurgias para correção do aneurisma de aorta infrarrenal realizadas no período de uma década (de 2008 a 2017) foram estudadas utilizando-se plataformas publicamente disponíveis do Sistema Único de Saúde e do Departamento de Informática do Sistema Único de Saúde. Resultados: Foram analisados ​​2.693 procedimentos, entre os quais 66,73% eram endovasculares. Entre os pacientes, houve predominância do sexo masculino (78,7%) e daqueles com 65 anos ou mais (70,7%). Um total de 64,02% eram admissões hospitalares eletivas. Ocorreram 288 óbitos hospitalares (mortalidade: 10,69%). A mortalidade durante a internação foi menor para cirurgia endovascular do que para cirurgia aberta tanto no contexto eletivo (4,13% versus 14,42%) quanto urgente (9,73% versus 27,94%) (p = 0,019). O maior volume (n = 635) apresentou menor mortalidade intra-hospitalar (3,31%). Foi pago um total de $24.835.604,84, sendo uma média de $2.318,63 para cirurgia abertura eletiva, $3.420,10 para cirurgia abertura de emergência, $12.157,35 para cirurgia endovascular eletiva e $12.969,12 para cirurgia endovascular na urgência. Os custos dos procedimentos endovasculares foram estatisticamente superiores aos valores pagos para as cirurgias abertas (p < 0,001). Conclusões: Foram realizadas duas vezes mais cirurgias endovasculares do que abertas, as quais apresentaram menor tempo de internação e menor mortalidade.

Epidemiological analysis of lower limb revascularization for peripheral arterial disease over 12 years on the public healthcare system in Brazil.

Background: Worldwide, peripheral arterial disease (PAD) is a disorder with high morbidity, affecting more than 200 million people. Objectives: Our objective was to analyze surgical treatment for PAD provided on the Brazilian Public Healthcare System over 12 years using publicly available data. Methods: The study was conducted with analysis of data available on the Brazilian Health Ministry's database platform, assessing distributions of procedures and techniques over the years and their associated mortality and costs. Results: A total of 129,424 procedures were analyzed (performed either for claudication or critical ischemia, proportion unknown). The vast majority of procedures were endovascular (65.49%) and this disproportion exhibited a rising trend (p<0.001). There were 3,306 in-hospital deaths (mortality of 2.55%), with lower mortality in the endovascular group (1.2% vs. 5.0%, p=0.008). The overall governmental expenditure on these procedures was U$ 238,010,096.51, and endovascular procedures were on average significantly more expensive than open surgery (U$ 1,932.27 vs. U$ 1,517.32; p=0.016). Conclusions: Lower limb revascularizations were performed on the Brazilian Public Healthcare System with gradually increasing frequency from 2008 to 2019. Endovascular procedures were vastly more common and were associated with lower in-hospital mortality rates, but higher procedure costs.

Contexto: A doença arterial periférica (DAP) é uma doença com alta morbidade global, afetando mais de 200 milhões de pessoas. Objetivos: Neste estudo, analisamos o tratamento cirúrgico para DAP no sistema público de saúde do Brasil no período de 12 anos, com base em dados publicamente disponíveis. Métodos: O estudo foi conduzido a partir da análise de dados disponíveis na plataforma do Departamento de Informática do Sistema Único de Saúde (DATASUS), do Ministério da Saúde, avaliando a distribuição da técnica cirúrgica utilizada, a mortalidade e o custo ao longo dos anos. Resultados: Um total de 129.424 procedimentos foram analisados (para claudicantes e isquemia crítica, em proporção desconhecida). A maiora dos procedimentos foi via endovascular (65,49%), com tendência de aumento nessa desproporção (p < 0,001). Houve 3.306 mortes intra-hospitalares (mortalidade de 2,55%) com menor mortalidade no grupo endovascular (1,2% vs. 5,0%; p = 0,008). O investimento governamental total para esses procedimentos foi de US$ 238.010.096,51, e os procedimentos endovasculares foram significativamente mais caros que a cirurgia aberta convencional (US$ 1.932,27 vs. US$ 1.517,32; p = 0,016). Conclusões: No sistema público de saúde brasileiro, as revascularizações de membros inferiores ocorreram com frequência crescente entre 2008 e 2019. Os procedimentos endovasculares foram mais comuns e relacionados a menor mortalidade intra-hospitalar, mas a maiores custos.

Epidemiological Analysis of 37,424 Carotid Artery Stenosis Intervention Procedures During 11 Years in the Public Health System in Brazil: Stenting has Been More Common Than Endarterectomy.

BACKGROUND: Stroke is a leading cause of death worldwide, with carotid atherosclerosis accounting for 10-20% of cases. In Brazil, the Public Health System provides care for roughly two-thirds of the population. No studies, however, have analysed large-scale results of carotid bifurcation surgery in Brazil. METHODS: This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2019 in the country through web scraping of publicly available databases. RESULTS: Between 2008 and 2019, 37,424 carotid bifurcation revascularization procedures were performed, of which 22,578 were CAS (60.34%) and 14,846 (39.66%) were CEA. There were 620 in-hospital deaths (1.66%), 336 after CAS (1.48%) and 284 after CEA (1.92%) (P = 0.032). Governmental reimbursement was US$ 77,216,298.85 (79.31% of all reimbursement) for CAS procedures and US$ 20,143,009.63 (20.69%) for CEA procedures. The average cost per procedure for CAS (US$ 3,062.98) was higher than that for CEA (US$ 1,430.33) (P = 0.008). CONCLUSIONS: In Brazil, the frequency of CAS largely surpassed that of CEA. In-hospital mortality rates of CAS were significantly lower than those of CEA, although both had mortality rates within the acceptable rates as dictated by literature. The cost of CAS, however, was significantly higher. This is a pioneering analysis of carotid artery disease management in Brazil that provides, for the first time, preliminary insight into the fact that the low adoption of CEA in the country is in opposition to countries where utilization rates are higher for CEA than for CAS.

Lower Limb Revascularization for Peripheral Arterial Disease in 10,951 Procedures over 11 years in a Public Health System: A Descriptive Analysis of the Largest Brazilian City.

BACKGROUND: Worldwide, peripheral arterial disease (PAD) is a disease with high morbidity, affecting more than 200 million people. Our objective was to analyze the surgical treatment for PAD performed in the Unified Health System of the city of São Paulo during the last 11 years based on publicly available data. METHODS: The study was conducted with data analysis available on the TabNet platform, belonging to the DATASUS. Public data (government health system) from procedures performed in São Paulo between 2008 and 2018 were extracted. Sex, age, municipality of residence, operative technique, number of surgeries (total and per hospital), mortality during hospitalization, mean length of stay in the intensive care unit and amount paid by the government system were analyzed. RESULTS: A total of 10,951 procedures were analyzed (either for claudicants or critical ischemia-proportion unknown); 55.4% of the procedures were performed on males, and in 50.60%, the patient was older than 65 years. Approximately two-thirds of the patients undergoing these procedures had residential addresses in São Paulo. There were 363 in-hospital deaths (mortality of 3.31%). The hospital with the highest number of surgeries (n = 2,777) had lower in-hospital mortality (1.51%) than the other hospitals. A total of $20,655,272.70 was paid for all revascularizations. CONCLUSIONS: Revascularization for PAD treatment has cost the government system more than $20 million over 11 years. Endovascular surgeries were performed more often than open surgeries and resulted in shorter hospital stays and lower perioperative mortality rates.

Inferior Vena Cava Filter in Cancer Patients: On Whom Should We Be Placing Them?

BACKGROUND: Standard treatment for venous thromboembolism is anticoagulation; vena cava filter placement is an alternative in special situations. We aimed to evaluate the outcomes in patients with cancer undergoing filter placement in a cancer center during a 10-year period and assess which preoperatory variables were associated with poorer survival. METHODS: Retrospective unicenter analysis during a 10-year period was carried out in patients with cancer who had undergone placement of vena cava filter. Early deaths were those that occurred less than 30 days after the filter placement or that occurred during the same hospital stay of the placement. RESULTS: About 250 patients were analyzed. About 51.6% were females; 77.2% had proximal lower limb deep vein thrombosis; 34.8% had contraindications to anticoagulation; 32.8% presented bleeding after the onset of anticoagulation; and 18.4% had the filter implanted because they were going to undergo surgery and could not be anticoagulated immediately after. About 51.2% of the filters were removable. However, only 2 had the filter removed. About 59.2% had metastatic disease at the time of filter placement. About 31.2% fulfilled criteria for early death. Of those, 34 patients were put in palliative care after filter insertion (median, 13.5 days). Body mass index >18 kg/m2, the absence of metastatic disease, and filter placement during the same anesthesia of another surgery (especially if elective and curative) were associated with a higher chance of survival. CONCLUSIONS: Multidisciplinary evaluation (and possibly consideration for palliation) should take place before the decision to insert a vena cava filter in severe oncologic cases depending on overall status. Patients with a greater chance of survival at a 3 or 5 years interval seem to be those whose filters were placed in the perioperative context of other surgeries (specially elective and curative), who were not undernourished, and whose disease was not metastatic at that time. For patients who survived, an active investigation protocol for filter removal should be implemented.

Anxiety and Depression Scores in Patients Subjected to Arterial Revascularization for Critical Limb Ischemia.

OBJECTIVES: This study aims to examine the changes in anxiety and depression scores in 138 patients with critical limb ischemia (rest pain or gangrene) who had no previous psychiatric history, at 30 days and 6 months after surgical revascularization. METHODS: Patients were submitted to a questionnaire-based evaluation using the Beck Anxiety and Depression Inventories before surgery (no more than three days before surgery) ("Pre-Op"), 30 days after surgical revascularization ("Early PO") and at least 6 months after surgical revascularization ("Late PO"). The cut-off scores for depression were (1) < 10, no depression or minimal depression; (2) 10‒18, mild to moderate depression; (3) 19‒29, moderate to severe depression; and (4) 30‒63, severe depression. The cut-off scores for anxiety were (1) < 8, no anxiety or minimal anxiety; (2) 8‒15, mild anxiety; (3) 16‒25, moderate anxiety; and (4) 26‒63, severe anxiety. RESULTS: No perioperative mortality was observed 30 days after surgical revascularization. Thirty-nine (28.2%) patients underwent major (above-ankle) amputation within 30 days. Mean anxiety and depression scores, respectively, declined from 12.48 ± 9.74 (mean ± SD) and 16.92 ± 12.48 preoperatively to 4.89 ± 7.04 and 6.52 ± 9.36 postoperatively (P<0.001, both). Anxiety and depression scores were not significantly affected by preoperative comorbidities (systemic arterial hypertension, diabetes mellitus, previous stroke, and smoking), affected arterial territory (aortoiliac, femoropopliteal, or infrapopliteal), or surgical technique (open surgery vs endovascular therapy). Only patients undergoing amputation within 30 days showed no improvement in depressive symptoms. CONCLUSIONS: Patients with critical limb ischemia have a high incidence of anxiety and depressive symptoms, which improve considerably after successful surgical revascularization. Major amputation was associated with a lack of improvement in depression scores. A formal psychiatric evaluation may be beneficial in patients who show no improvement in depressive symptoms.

Initial experience with Duplex scan combined with contrast-enhanced ultrasound for follow-up of endovascular abdominal aortic aneurysm repair.

Background: Microbubble contrast enhanced ultrasound (CEUS) is an accurate diagnostic method for follow-up after endovascular abdominal aortic aneurysm repair (EVAR) that has been well-established in international studies. However, there are no Brazilian studies that focus on this follow-up method. Objectives: The objective of this study was to report initial experience with CEUS at a tertiary hospital, comparing the findings of CEUS with those of conventional Doppler ultrasound (DUS), with the aim of determining whether addition of contrast to the standard ultrasonographic control protocol resulted in different findings. Methods: From 2015 to 2017, 21 patients in follow-up after EVAR underwent DUS followed by CEUS. The findings of these examinations were analyzed in terms of identification of complications and their capacity to identify the origin of endoleaks. Results: There was evidence of complications in 10 of the 21 cases examined: seven patients exhibited endoleaks (33.3%); two patients exhibited stenosis of a branch of the endograft (9.52%); and one patient exhibited a dissection involving the external iliac artery (4.76%). In the 21 patients assessed, combined use of both methods identified 10 cases of post-EVAR complications. In six of the seven cases of endoleaks (85.71%), use of the methods in combination was capable of identifying the origin of endoleakage. DUS alone failed to identify endoleaks in two cases (28.5%) and identified doubtful findings in another two cases (28.5%), in which diagnostic definition was achieved after employing CEUS. Conclusions: CEUS is a technique that is easy to perform and provides additional support for follow-up of infrarenal EVAR.

Epidemiological Analysis of Carotid Artery Stenosis Intervention during 10 years in the Public Health System in the Largest City in Brazil: Stenting Has Been More Common than Endarterectomy.

BACKGROUND: Stroke is the second leading cause of death worldwide with approximately 5.7 million cases/year, and carotid atherosclerosis accounts for 10 to 20% of cases. METHODS: In Brazil, the Unified Health System (Sistema Único de Saúde [SUS]) is a tax-funded public health care system that provides care for roughly half the population. São Paulo is the eighth largest city in the world with an estimated population of over 12 million people, of whom more than 5 million rely solely on SUS. This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2017 in the city of São Paulo through web scraping of publicly available databases. RESULTS: Three thousand seven hundred and four carotid revascularization procedures were performed between 2008 and 2017, of which 2,432 were CAS (65.7%). Rates of CAS ranged from 59.9% in 2016 to 86% in 2011. There were 57 in-hospital deaths (1.54%), 34 after CAS (1.4%; 34/2,432) and 23 after CEA (1.81%; 23/1,272) (P = 0.562). SUS reimbursements were US $7,862,017.09 (81.44% of all reimbursements) for 2,432 CAS procedures and US $1,792,324.06 (18.56%) for 1,272 CEA procedures. Average SUS reimbursement for CAS (US $3,232.73) was more than double than that for CEA (US $1,409.05). CONCLUSIONS: In a city whose population exceeds that of some European countries, costs of CAS and CEA to the public health care system totaled more than US$ 9 million over 10 years. Epidemiologically, CAS was performed more commonly than CEA with no difference in in-hospital mortality between CAS and CEA, but reimbursements were 2.29 times higher for CAS. The low adoption of CEA in São Paulo is in contrast to countries where utilization rates are higher for CEA than for CAS.