Epidemiological Analysis of 12 Years of Open Thoracoabdominal Aortic Aneurysm Repair in the Brazilian Public Health System

ABSTRACT Introduction: Although endovascular correction is a promising perspective, the gold-standard treatment for thoracoabdominal aortic aneurisms and type-B dissections with visceral involvement remains open surgery, particularly due to its well-established long-term durability. This study aims to describe and evaluate public data from patients treated for thoracoabdominal aortic aneurism in the Brazilian public health system in a 12-year interval. Methods: Data from procedures performed between 2008 and 2019 were extracted from the national public database (Departamento de Informática do Sistema Único de Saúde, or DATASUS) using web scraping techniques. Procedures were evaluated regarding the yearly frequency of elective or urgency surgeries, in-hospital mortality, and governmental costs. All tests were done with a level of significance P<0.05. Results: A total of 812 procedures were analyzed. Of all surgeries, 67.98% were elective cases. There were 328 in-hospital deaths (mortality of 40.39%). In-hospital mortality was lower in elective procedures (26.92%) than in urgency procedures (46.74%) (P=0.008). Total governmental expenditure was $3.127.051,56 — an average of $3.774,22 for elective surgery and $3.791,93 for emergency surgery (P=0.999). Conclusion: The proportion of urgency procedures is higher than that recommended by international literature. Mortality was higher for urgent admissions, although governmental costs were equal for elective and urgent procedures; specialized referral centers should be considered by health policy makers.

Epidemiological analysis of 556 procedures of open thoracoabdominal aortic aneurysm repair in the Public Health System in the largest Brazilian city

ABSTRACT Objective Despite the development of endovascular procedures, open repair remains the gold standard for the treatment of aortic thoracoabdominal aneurysms and some type B dissections, with well-established good outcomes and long-term durability at high-volume centers. The present study described and analyzed public data from patients treated in the public system in a 12-year interval, in a city where more than 5 million inhabitants depend on the Public Health System. Methods Public data from procedures performed between 2008 and 2019 were extracted using web scraping techniques. The variables available in the database include sex, age, elective or emergency hospital admission, number of surgeries, in-hospital mortality, length of stay, and information on reimbursement values. Results A total of 556 procedures were analyzed. Of these, 60.79% patients were men, and 41.18% were 65 years of age or older. Approximately 60% had a residential address registered in the municipality. Of all surgeries, 65.83% were elective cases. There were 178 in-hospital deaths (mortality of 32%). In the elective context, there were 98 deaths 26.78% versus 80 deaths (42.10%) in the emergency context (p=0.174). Mortality was lower in the hospitals that performed more surgeries. A total of USD 3,038,753.92 was paid, an average of USD 5,406.95 for elective surgery and USD 5,074.76 for emergency surgery (p=0.536). Conclusion Mortality was no different between groups, and hospitals with higher volume presented more favorable outcomes. Specialized referral centers should be considered by health policy makers.

Morphological and hemodynamic patterns of carotid stenosis treated by endarterectomy with patch closure versus stenting: a duplex ultrasound study

OBJECTIVES: A duplex ultrasound study was performed to investigate morphological and hemodynamic patterns of carotid stenoses treated by endarterectomy with patch closure versus stenting. MATERIALS AND METHOD: Twenty-nine carotid stenoses were treated with stenting and 65 with patch closure. Duplex ultrasound parameters (luminal diameter, mm; peak systolic velocity and end-diastolic velocity, cm/s) were measured 24 hours after the procedures and also at 12 months post-procedure. Residual stenoses (immediately postprocedure) and restenoses (within 12 months of procedure) were defined as narrowings of >50 percent on duplex ultrasound examination. RESULTS: In stented patients, the luminal diameter of the proximal internal carotid artery increased in the interval between the 24-hour and 12-month post-procedure studies, while in the patch closure patients, the diameter decreased. Carotid hemodynamics normalized immediately after both patching and stenting and remained relatively stable thereafter up to 12 months. No statistically elevated flow velocities (in the absence of residual stenosis or restenosis) were observed in the patched or stented carotid arteries. No significant differences in residual stenosis rates were observed between the stenting group (3 cases, 10.34 percent) and the patch closure group (1 case, 1.53 percent, P = 0.08). At 12 months, 2 stenting patients (6.88 percent) and 2 patch closure patients (3.07 percent) had $50 percent restenosis (P = 0.58). One case of late stroke due to restenosis was observed in the stenting group; the patient died 12 months postoperatively, before receiving new intervention. CONCLUSION: Measurements over time in luminal diameter signalized differences in arterial remodeling mechanisms between patched and stented carotids. Both stenting and patch closure were associated with carotid patency and flow restoration. This study does not support a general approach to new velocity criteria indiscriminately applied to stented or patched carotids.

Avaliação do perfil lipídico na doença arterial periférica / Evaluation of lipid profile in the peripheral arterial disease

Objetivo: Analisar o perfil lipídico na doença arterial periférica e avaliar a influência desse fator, além da idade, na doença arterial periférica obstrutiva ou aneurismática. Método: Foram estudados 124 indivíduos, 62 pacientes com doença arterial periférica aneurismática confirmada por angiografia e 62 controles. Foram dosados os níveis séricos de lipoproteína (a), triglicérides, colesterol total e frações do colesterol de lipoproteínas de baixa (LDLc), alta (HDLc) e muito baixa densidade (VLDLc)...

Fenestração aórtica endovascular na dissecção aguda complicada por isquemia visceral e perfiérica / Endovascular aortic fenestration for acute dissection complicated by visceral and peripheral ischemia

Os autores relatam um caso de tratamento paliativo de isquemia periférica causada por dissecção aguda da aorta tipo B de Stanford por meio de fenestração aórtica endovascular. Mais de 90 por cento dos pacientes com dissecção aaguda da aorta, se não tratados, morrem em 3 a 6 meses. O tratamento clínico inicial e definitivo para dissecção aguda da aorta do tipo B é preconizado pela maioria dos importantes centros, reservando-se o tratamento cirúrgico para suas complicações, como isquemia periférica, que é a mais frequente, ocorrendo em 35 por cento das vezes. Os autores também descrevem aspectos da fenestração cirúrgica cnvencional, comparandoa coma técnica percutânea.

Polimorfismo genético da apolipoproteína E na doença arterial periférica / Genetic polymorphism of apolipoprotein E in peripheral artery disease

Objetivo: este estudo teve corno objetivo analisar o polimorfismo genético da apolipoproteína E na doença arterial periférica obstrutiva ou aneurismática.Método: foram estudados 61 pacientes caucasóides do sexo masculino com sintomas clínicos e comprovação angiográfica de doença aterosclerótica, com idade entre 38 e 79 anos. O grupo-controle foi constituído por 59 indivíduos. Foram excluídos os indivíduos com doença renal, doença hepática ou diabetes melito. A análise dopolimorfismo genético da apolipoproteína E foi realizada por PCR(polimerase chain reaction) e RFLP (restriction fragment lenght polimorphism) com a endonuclease Hha I, identificando-se seis genótipos: 2/2, 2/3, 2/4, 3/3,3/4 e 4/4. Para análise estatística, foram aplicados teste exato de Fisher e odds ratio, com intervalo de confiança de 95 por cento, e admitiu-se erro a de até 5 por cento.Resultados: O alelo 3 mostrou-se mais freqüente em pacientes e controles, enquanto o alelo 4 apresentou maior prevalência nos controles em relação aos pacientes, embora sem diferença significante entre eles. Pacientes com doença arterial periférica obstrutiva mostrararo freqüência mais elevada do genótipo 3/4 em comparação àdoença arterial periférica aneurismática, embora sem diferença significante entre eles.Conclusão: o polimorfismo da apolipoproteína E-Hha I não foiassociada com a doença arterial periférica.

Polimorfismo genético do fibrinogênio na doença arterial periférica / Genetic polymorphisms of fibrinogen in peripheral artery disease

O objetivo do presente estudo foi analisar freqüências alélicas e genotípicas para o gene codificador da cadeia beta do fibrinogênio em pacientes com doença arterial periférica (DAP). Foram estudados 44 pacientes caucasóides do sexo masculino com sintomas clínicos e comprovação angiográfica de DAP, com idade entre 38 e 79 anos (62±8,6 anos). Entre eles, 22 apresentaram obstrução aterosclerótica nas artérias ilíacas, femorais e/ou carótidas e 22 tinham aneurisma de aorta torácica, abdominal ou tóraco-abdominal. O grupo controle foi constituído por 56 indivíduos, sem história clínica de DAP ou alterações ao exame clínico, com idades variando de 43 a 80 anos (59±9,2 anos). Foram excluídos os indivíduos com doença renal, doença hepática ou diabetes mellitus. A análise do polimorfismo genético da cadeia do fibrinogênio foi realizada por PCR (polimerase chain reaction) e RFLP (restriction fragment lenght polimorphism) com a endonuclease Bcl I, identificando-se três genótipos: B1/B1, B1/B2 e B2/B2. A análise estatística incluiu teste exato de Fisher, calculo do odds ratio, teste de Kruskal Wallis e análise de variância (ANOVA). Admitiu-se erro a igual a 5 por cento, com nível de significância para P<0,05. O alelo B1 foi o mais prevalente em pacientes e controles (0,819 e 0,857, respectivamente; P=0,5605), com prevalência do genótipo B1/B1 nos pacientes (65,9 por cento) e controles (71,4 por cento; P=0,6639), seguido de B1/B2 (31,8; 28,6 por cento, respectivamente; P=0,8268). Em conclusão, DAP, independente do tipo de lesão obstrutiva ou aneurismática, apresenta-se indiferente ao polimorfismo Bcl I do fibrinogênio, portanto, sem influência dos alelos B1 e B2 para fibrinogênio e seus respectivos genótipos na doença.

The objective of this study was to analyze the frequencies of thealleles and genotypes of the gene encoder of the fibrinogen bchainin patients suffering from peripheral artery disease. A totalof 62 male Caucasoid patients with ages varying from 38 to 79years old were studied. All the patients had clinical symptoms ofperipheral artery disease, which was later confirmed byangiography. Forty of the patients had atheroscleroticobstructions of the iliac, femoral or carotid arteries and 22 sufferedfrom aneurysms of the thoracic, abdominal or thoracoabdominalaortas. All the patients were submitted to surgery. A controlgroup was formed of 62 individuals, with ages ranging from 43to 80 years old, without clinical histories or alterations in theirclinical examinations of peripheral artery disease. Individualswith renal disease, liver disease or diabetes mellitus wereexcluded. Analysis of the fibrinogen b-chain was performed usingpolymerase chain reaction and restriction fragment lengthpolymorphism with Bcl I endonuclease. Three genotypes, B1/B1,B1/B2 and B2/B2 were identified. Statistical analysis was madeusing the Fisher Exact test, odds ratio, Kruskal-Wallis test andvariance analysis (ANOVA). A p-value = 0.05 was consideredsignificant. The B1 allele was the most prevalent in both patientsand the control group (0.819 and 0.857, respectively), withprevalence of the B1/B1 genotype in patients and controls (65.9%vs. 71.4% respectively), followed by B1/B2 (31.8% vs. 28.6%respectively). No significant difference was observed in relationto the Bcl I polymorphisms of the fibrinogen b-chain andobstructive and aneurysmal peripheral artery disease. Inconclusion, the B1 and B2 polymorphisms of the fibrinogen bchain and teir respective genotypes do not have any influence in peripheral artery disease.

The use of stents in the treatment of traumatic intimal flaps: case report

Treatment of arterial traumatic intimal lesions is controversial due to its unknown natural history. Current therapeutical options include arterial reconstruction and clinical observation. The idea of using stents to correct intimal flaps is based on their use to correct dissections, flaps, and arterial irregularities after angioplasty. We report the successful treatment of a traumatic intimal flap of the superficial femoral artery, caused by gunshot trauma, with a Palmaz stent in the acute period. One year after the operation, a duplex scan revealed normal flow in the artery and complete exclusion of the intimal flap; distal pulses were palpable, and the patient was completely asymptomatic