Carbon Dioxide as Contrast Medium to Guide Endovascular Aortic Aneurysm Repair.

BACKGROUND: Iodine contrast medium (ICM) is considered to be gold standard in endovascular procedures, but its nephrotoxicity and hypersensitivity limit the widespread use. Carbon dioxide (CO2) is considered as an alternative for endovascular procedures in patients with contraindication to ICM. However, no studies have compared the outcomes of endovascular aneurysm repair (EVAR) performed with ICM or CO2 among patients with no contraindication to ICM. METHODS: From May 2012 to April 2014, 36 patients with abdominal aortic aneurysms underwent EVAR in a prospective, randomized, and controlled study. Patients were randomized into 2 groups, CO2 or ICM group. RESULTS: We were able to perform the proposed procedures in all patients in this study. There were no conversions to open surgery and no CO2-related complications. Endovascular material costs, duration of surgery, and time of fluoroscopy were similar between groups, and the cost of the contrast media was smaller in the CO2 group than in the ICM group. Among CO2 group procedures, 62.5% of the patients needed ICM complementary use. CONCLUSIONS: The use of CO2 as a contrast medium for EVAR is an alternative in patients with no restriction for ICM, with similar outcomes when compared to ICM, regarding duration of surgery, duration of fluoroscopy, and endovascular material costs. Using CO2, there were no changes in creatinine clearance and no risk of hypersensitivity reactions; moreover, there was a reduction in contrast-related costs for EVAR procedures. However, in our study, additional use of ICM to visualize the internal iliac artery was needed in most procedures.

Oral Rivaroxaban for the Treatment of Symptomatic Venous Thromboembolism in 400 Patients With Active Cancer: A Single-Center Experience.

PURPOSE: To study the safety and efficacy of rivaroxaban-a direct oral anticoagulant-use in patients with active cancer and venous thromboembolism (VTE). PATIENTS AND METHODS: Retrospective cohort study of 400 patients with active cancer and associated VTE, defined as deep venous thrombosis and/or pulmonary embolism. This single-center study was carried out from January 2012 to June 2015. The aim of this study was to determine the efficacy and safety, using the incidence of recurrent symptomatic VTE and major bleeding, respectively, throughout the treatment with rivaroxaban. RESULTS: Of the 400 patients enrolled, 223 (55.8%) were female. A total of 362 (90.5%) patients had solid tumors and 244 (61%) had metastatic disease. A total of 302 (75.5%) received initial parenteral therapy with enoxaparin (median: 3, mean: 5.6, standard deviation [SD]: 6.4 days) followed by rivaroxaban. Ninety-eight patients (24.5%) were treated with on label rivaroxaban treatment. Recurrence rates were 3.25% with major bleeding occurring in 5.5% during the anticoagulant therapy (median: 118, mean: 163.9, SD: 159.9 days). CONCLUSION: Rivaroxaban can be an attractive alternative for the treatment of cancer-associated thrombosis.

Endovascular revascularization of TASC C and D femoropopliteal occlusive disease using carbon dioxide as contrast.

OBJECTIVE: To analyze the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO2 as primary contrast in patients with no formal contraindication to iodine, aiming to decrease allergic reactions and potential nephrotoxicity in high-risk patients. METHODS: We describe the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO2 as primary contrast in patients with high risk for open revascularization and no formal contraindication to iodine. We analyzed feasibility of the procedures, complications, quality of the angiographic images, clinical and surgical outcomes, and costs of C and D lesions treated using CO2 as contrast medium. RESULTS: The use of CO2 in C and D lesions needed iodine complementation in most of the cases (nine cases) but decreased the potential nephrotoxicity of iodine contrast medium by the reduction of its volume in this group of high-risk patients. The extension of the arterial lesions was the factor that most contributed to the need for iodine supplementation due to the difficulty to visualize the refill after a long arterial occlusion. CONCLUSION: The use of CO2 as contrast in patients with C and D lesions with no restriction for iodine contrast medium was an alternative that did not dismiss the need of iodine supplementation in most of the cases, but could decrease the potential nephrotoxicity of iodine constrast medium. OBJETIVO: Analisar os resultados de dez angioplastias de lesões fêmoro-poplíteas TASC C e D utilizando CO2 como meio de contraste primário em pacientes sem restrição ao meio de contraste iodado com o objetivo de diminuir reações alérgicas e potencial de nefrotoxicidade em pacientes de alto risco. MÉTODOS: Descrevemos os resultados de dez angioplastias de lesões fêmoro-poplíteas TASC C e D utilizando CO2 como meio de contraste primário em pacientes de alto risco para revascularização aberta e sem contraindicação formal a iodo. Analisamos possibilidade de execução dos procedimentos, complicações, qualidade das imagens obtidas, desfechos clínicos e cirúrgicos e custos das lesões C e D tratadas com CO2 como meio de contraste. RESULTADOS: O uso de CO2 nas lesões C e D necessitou de complementação de iodo na maioria dos casos (nove casos), porém reduziu o potencial de nefrotoxicidade do meio de contraste iodado, diminuindo seu volume nesse grupo de pacientes de alto risco. A extensão das lesões arteriais foi o fator que mais contribuiu para necessidade de suplementação de iodo, devido à dificuldade de visualizar o reenchimento após oclusão arterial longa. CONCLUSÃO: O uso de CO2 como contraste em pacientes com lesões C e D sem restrição ao meio de contraste iodado foi uma alternativa que não excluiu a necessidade de suplementação com iodo na maioria dos casos, porém pôde diminuir o potencial de nefrotoxicidade do meio de contraste iodado.

Endovascular revascularization of TASC C and D femoropopliteal occlusive disease using carbon dioxide as contrast / Revascularização endovascular de doença oclusiva fêmoro-poplítea TASC C e D com o uso de dióxido de carbono como meio de contraste

ABSTRACT Objective To analyze the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO2 as primary contrast in patients with no formal contraindication to iodine, aiming to decrease allergic reactions and potential nephrotoxicity in high-risk patients. Methods We describe the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO2 as primary contrast in patients with high risk for open revascularization and no formal contraindication to iodine. We analyzed feasibility of the procedures, complications, quality of the angiographic images, clinical and surgical outcomes, and costs of C and D lesions treated using CO2 as contrast medium. Results The use of CO2 in C and D lesions needed iodine complementation in most of the cases (nine cases) but decreased the potential nephrotoxicity of iodine contrast medium by the reduction of its volume in this group of high-risk patients. The extension of the arterial lesions was the factor that most contributed to the need for iodine supplementation due to the difficulty to visualize the refill after a long arterial occlusion. Conclusion The use of CO2 as contrast in patients with C and D lesions with no restriction for iodine contrast medium was an alternative that did not dismiss the need of iodine supplementation in most of the cases, but could decrease the potential nephrotoxicity of iodine constrast medium.

RESUMO Objetivo Analisar os resultados de dez angioplastias de lesões fêmoro-poplíteas TASC C e D utilizando CO2 como meio de contraste primário em pacientes sem restrição ao meio de contraste iodado com o objetivo de diminuir reações alérgicas e potencial de nefrotoxicidade em pacientes de alto risco. Métodos Descrevemos os resultados de dez angioplastias de lesões fêmoro-poplíteas TASC C e D utilizando CO2 como meio de contraste primário em pacientes de alto risco para revascularização aberta e sem contraindicação formal a iodo. Analisamos possibilidade de execução dos procedimentos, complicações, qualidade das imagens obtidas, desfechos clínicos e cirúrgicos e custos das lesões C e D tratadas com CO2 como meio de contraste. Resultados O uso de CO2 nas lesões C e D necessitou de complementação de iodo na maioria dos casos (nove casos), porém reduziu o potencial de nefrotoxicidade do meio de contraste iodado, diminuindo seu volume nesse grupo de pacientes de alto risco. A extensão das lesões arteriais foi o fator que mais contribuiu para necessidade de suplementação de iodo, devido à dificuldade de visualizar o reenchimento após oclusão arterial longa. Conclusão O uso de CO2 como contraste em pacientes com lesões C e D sem restrição ao meio de contraste iodado foi uma alternativa que não excluiu a necessidade de suplementação com iodo na maioria dos casos, porém pôde diminuir o potencial de nefrotoxicidade do meio de contraste iodado.

Carbon dioxide contrast medium for endovascular treatment of ilio-femoral occlusive disease.

OBJECTIVES: Compare the use of carbon dioxide contrast medium with iodine contrast medium for the endovascular treatment of ilio-femoral occlusive disease in patients without contraindications to iodine. MATERIALS AND METHODS: From August 2012 to August 2014, 21 consecutive patients with ilio-femoral occlusive disease who were eligible for endovascular treatment and lacked contraindications to either iodine contrast or carbon dioxide were randomized into the carbon dioxide or iodine groups and subjected to ilio-femoral angioplasty.We analyzed the feasibility of the procedures, the surgical and clinical outcomes, the procedure lengths, the endovascular material costs, the contrast costs and the quality of the angiographic images in each group. RESULTS: No conversions to open surgery and no contrast media related complications were noted in either group. A post-operative femoral pulse was present in 88.9% of the iodine group and 80% of the carbon dioxide group. No differences in procedure length, endovascular material cost or renal function variation were noted between the groups. Four patients in the carbon dioxide group required iodine supplementation to complete the procedure. Contrast media expenses were reduced in the carbon dioxide group. Regarding angiographic image quality, 82% of the carbon dioxide images were graded as either good or fair by observers. CONCLUSIONS: The use of carbon dioxide contrast medium is a good option for ilio-femoral angioplasty in patients without contraindications to iodine and is not characterized by differences in endovascular material costs, procedure duration and surgical outcomes. In addition, carbon dioxide has lower contrast expenses compared with iodine.

Carbon dioxide contrast medium for endovascular treatment of ilio-femoral occlusive disease

OBJECTIVES:Compare the use of carbon dioxide contrast medium with iodine contrast medium for the endovascular treatment of ilio-femoral occlusive disease in patients without contraindications to iodine.MATERIALS AND METHODS:From August 2012 to August 2014, 21 consecutive patients with ilio-femoral occlusive disease who were eligible for endovascular treatment and lacked contraindications to either iodine contrast or carbon dioxide were randomized into the carbon dioxide or iodine groups and subjected to ilio-femoral angioplasty.We analyzed the feasibility of the procedures, the surgical and clinical outcomes, the procedure lengths, the endovascular material costs, the contrast costs and the quality of the angiographic images in each group.RESULTS:No conversions to open surgery and no contrast media related complications were noted in either group. A post-operative femoral pulse was present in 88.9% of the iodine group and 80% of the carbon dioxide group. No differences in procedure length, endovascular material cost or renal function variation were noted between the groups. Four patients in the carbon dioxide group required iodine supplementation to complete the procedure. Contrast media expenses were reduced in the carbon dioxide group. Regarding angiographic image quality, 82% of the carbon dioxide images were graded as either good or fair by observers.CONCLUSIONS:The use of carbon dioxide contrast medium is a good option for ilio-femoral angioplasty in patients without contraindications to iodine and is not characterized by differences in endovascular material costs, procedure duration and surgical outcomes. In addition, carbon dioxide has lower contrast expenses compared with iodine.

Treatment of uncommon sites of focal primary hyperhidrosis: experience with pharmacological therapy using oxybutynin.

OBJECTIVES: Primary hyperhidrosis usually affects the hands, armpits, feet and cranio-facial region. Sweating in other areas is common in secondary hyperhidrosis (after surgery or in specific clinical conditions). Oxybutynin has provided good results and is an alternative for treating hyperhidrosis at common sites. Our aim was to evaluate the efficacy of oxybutynin as a treatment for primary sweating at uncommon sites (e.g., the back and groin). METHODS: This retrospective study analyzed 20 patients (10 females) who received oxybutynin for primary focal hyperhidrosis at uncommon sites. The subjects were evaluated to determine quality of life before beginning oxybutynin and six weeks afterward and they were assigned grades (on a scale from 0 to 10) to measure their improvement at each site of excessive sweating after six weeks and at the last consult. RESULTS: The median follow-up time with oxybutynin was 385 days (133-1526 days). The most common sites were the back (n = 7) and groin (n = 5). After six weeks, the quality of life improved in 85% of the subjects. Dry mouth was very common and was reported by 16 patients, 12 of whom reported moderate/severe dry mouth. Five patients stopped treatment (two: unbearable dry mouth, two: excessive somnolence and one: palpitations). At the last visit, 80% of patients presented with moderate/great improvement at the main sites of sweating. CONCLUSION: After six weeks, more than 80% of the patients presented with improvements in their overall quality of life and at the most important site of sweating. Side effects were common (80% reported at least one side effect) and caused 25% of the patients to discontinue treatment. Oxybutynin is effective for treating bothersome hyperhidrosis, even at atypical locations and most patients cope well with the side effects.

Treatment of uncommon sites of focal primary hyperhidrosis: experience with pharmacological therapy using oxybutynin

OBJECTIVES: Primary hyperhidrosis usually affects the hands, armpits, feet and cranio-facial region. Sweating in other areas is common in secondary hyperhidrosis (after surgery or in specific clinical conditions). Oxybutynin has provided good results and is an alternative for treating hyperhidrosis at common sites. Our aim was to evaluate the efficacy of oxybutynin as a treatment for primary sweating at uncommon sites (e.g., the back and groin). METHODS: This retrospective study analyzed 20 patients (10 females) who received oxybutynin for primary focal hyperhidrosis at uncommon sites. The subjects were evaluated to determine quality of life before beginning oxybutynin and six weeks afterward and they were assigned grades (on a scale from 0 to 10) to measure their improvement at each site of excessive sweating after six weeks and at the last consult. RESULTS: The median follow-up time with oxybutynin was 385 days (133-1526 days). The most common sites were the back (n = 7) and groin (n = 5). After six weeks, the quality of life improved in 85% of the subjects. Dry mouth was very common and was reported by 16 patients, 12 of whom reported moderate/severe dry mouth. Five patients stopped treatment (two: unbearable dry mouth, two: excessive somnolence and one: palpitations). At the last visit, 80% of patients presented with moderate/great improvement at the main sites of sweating. CONCLUSION: After six weeks, more than 80% of the patients presented with improvements in their overall quality of life and at the most important site of sweating. Side effects were common (80% reported at least one side effect) and caused 25% of the patients to discontinue treatment. Oxybutynin is effective for treating bothersome hyperhidrosis, even at atypical locations and most patients cope well with the side effects. .