Complications of central venous catheterization at a vascular surgery service in a teaching hospital: a prospective cohort study.

Background: Central venous catheters are essential for management of hospitalized patients, but their insertion is subject to complications that can make them unusable and/or cause patient morbidity. There are few data on the incidence of these complications and the variables associated with these outcomes in Brazil. Objectives: To determine the incidence of mechanical complications and failures of short stay central venous catheters fitted by the vascular surgery service at a teaching hospital and identify variables associated with their occurrence. Methods: This was a prospective cohort of 73 attempts to fit patients with a central venous catheter performed by the vascular surgery service at a teaching hospital from July to October of 2022. Results: Mechanical complications occurred in 12 cannulation attempts (16.44%) and there were 10 failures (13.70%). The factors associated with mechanical complications were less experienced operators (p < 0.001), less specialized operators (p = 0.014), a failed attempt prior to requesting help from the vascular surgery service (p = 0.008), and presence of at least two criteria for difficulty (p = 0.007). Conclusions: The local incidence of mechanical complications and central venous cannulation failures was similar to rates described in the international literature, but higher than rates in other Brazilian studies. The results suggest that the degree of experience of the person fitting the catheter, history of a failed prior attempt, and presence of at least two criteria for difficulty identified before the procedure were associated with worse outcomes.

Complicações de acessos venosos centrais em um serviço de cirurgia vascular de um hospital de ensino: uma coorte prospectiva / Complications of central venous catheterization at a vascular surgery service in a teaching hospital: a prospective cohort study

Resumo Contexto Os acessos venosos centrais são essenciais no manejo de pacientes hospitalizados; contudo, a sua inserção está sujeita a complicações que podem dificultar seu uso e causar morbidade aos pacientes. No Brasil, dados acerca da incidência dessas complicações e das variáveis associadas com esse desfecho são escassos. Objetivos Determinar a incidência de complicações mecânicas e de falhas de acessos venosos centrais de curta permanência realizados no serviço de Cirurgia Vascular de um hospital de ensino, além de identificar as variáveis associadas com a sua ocorrência. Métodos Tratou-se de uma coorte prospectiva com 73 tentativas de acesso venoso central realizadas em pacientes assistidos pelo serviço de Cirurgia Vascular de um hospital de ensino entre julho e outubro de 2022. Resultados Complicações mecânicas ocorreram em 12 tentativas de acessos (16,44%), e falhas, em 10 tentativas (13,70%). Os fatores associados às complicações mecânicas foram menor experiência do operador (p < 0,001), menor grau de especialização do operador (p = 0,014), falha na tentativa de acesso precedente à solicitação de auxílio ao serviço de Cirurgia Vascular (p = 0,008) e presença de pelo menos dois critérios de dificuldade (p = 0,007). Conclusões A incidência local de complicações mecânicas e de falhas dos acessos venosos centrais foi semelhante à descrita na literatura internacional, mas foi superior à descrita em trabalhos brasileiros. Os resultados sugerem que o grau de experiência do executor do acesso, a história de falha em tentativa precedente e a presença de pelo menos dois critérios de dificuldade verificados antes do procedimento estão associados com piores desfechos.

Abstract Background Central venous catheters are essential for management of hospitalized patients, but their insertion is subject to complications that can make them unusable and/or cause patient morbidity. There are few data on the incidence of these complications and the variables associated with these outcomes in Brazil. Objectives To determine the incidence of mechanical complications and failures of short stay central venous catheters fitted by the vascular surgery service at a teaching hospital and identify variables associated with their occurrence. Methods This was a prospective cohort of 73 attempts to fit patients with a central venous catheter performed by the vascular surgery service at a teaching hospital from July to October of 2022. Results Mechanical complications occurred in 12 cannulation attempts (16.44%) and there were 10 failures (13.70%). The factors associated with mechanical complications were less experienced operators (p < 0.001), less specialized operators (p = 0.014), a failed attempt prior to requesting help from the vascular surgery service (p = 0.008), and presence of at least two criteria for difficulty (p = 0.007). Conclusions The local incidence of mechanical complications and central venous cannulation failures was similar to rates described in the international literature, but higher than rates in other Brazilian studies. The results suggest that the degree of experience of the person fitting the catheter, history of a failed prior attempt, and presence of at least two criteria for difficulty identified before the procedure were associated with worse outcomes.

6-Month Follow-up of Lateral Femoral Circumflex Artery Embolization to Control Pain Related to Hip Osteoarthritis and Greater Trochanteric Pain Syndrome.

PURPOSE: To present the preliminary results of a cohort of 13 patients with hip osteoarthritis (OA) and great trochanteric pain syndrome (GTPS) refractory to conservative management or physical therapy and no indication for surgery treated with embolization of the lateral femoral circumflex artery. MATERIAL AND METHODS: This is a single-center prospective cohort from July 2019 to September 2020. Visual analogue scale (VAS) and Western Ontario and MacMaster Universities (WOMAC) were used to compare the symptoms before and after 6-month follow-up. Technical success was considered when at least one artery responsible for the hyperemic synovium was embolized. Complications and adverse events were noted. RESULTS: In total, 13 patients were included; mean age was 62.4 (± 11.0) years. 10 (76.9%) patients were treated for GTPS and 3 (23.1%) for hip OA. Nine patients were treated with imipenem/cilastatin (I/C) alone. Microsphere 100-300 µm and I/C were combined in 4 patients. The WOMAC Index had a statistically significant decrease in the total from 77 to 27 points (p = 0.001). Pain, rigidity and physical activity have also significantly reduced (19 to 5, p = 0.001; 6 to 2, p = 0.002 and 53 to 22, p = 0.001, respectively). VAS score had a significant decrease (10 to 2, p = 0.002). Two patients present posterior tight numbness, spontaneously improved within 30 days. CONCLUSION: In this cohort, lateral femoral circumflex artery embolization was a safe and effective treatment for patients with hip pain due to OA and GTPS.

GAUCHO - Trial Genicular Artery Embolization Using Imipenem/Cilastatin vs. Microsphere for Knee Osteoarthritis: A Randomized Controlled Trial.

Genicular artery embolization (GAE) has emerged as a treatment option to improve quality of life in patients suffering from moderate-to-severe pain refractory to conservative treatment of knee osteoarthritis, with encouraging results. This paper describes the study protocol of a single-center, double-blind, randomized controlled trial designed to evaluate and compare the safety and efficacy of GAE using imipenem/cilastatin vs. microspheres for the treatment of moderate-to-severe pain associated with knee osteoarthritis. We hypothesized that there will be no difference in safety and efficacy outcomes. The study received ethics approval of the institutional review board with number 4.364.391 / CAAE: 37590820.3.0000.5342 and is registered onto the Registro Brasileiro de Ensaios Clinicos (ReBEC), with number RBR-2h5rwgb. Technical success was defined as embolization of at least 1 feeding artery supplying the hyperemic synovium of the knee joint. Primary outcome: clinical success was defined as improvement in symptoms, 50% reduction in Western Ontario and McMaster Universities Osteoarthritis Index pain scores or an increase of at least 10 points in the Knee Injury and Osteoarthritis Outcome Score from baseline to 3 months of follow-up. Secondary outcome: radiological success was defined as significant improvement in the Whole-Organ Magnetic Resonance Imaging Score for knee synovitis considering the embolized areas at 12 months of follow-up after GAE and a reduction in the analgesia or other conservative therapies for knee pain used by the patient at 3 and 12 months of follow-up. Clinical assessments will be performed before GAE, during GAE and at hospital discharge (for Visual Analog Scale of pain), and at 30 days, 3 months, and 12 months after GAE.

Coarctation of the abdominal aorta associated with renovascular hypertension and incapacitating claudication: repair with iliac-birenal bypass and paving and cracking technique.

Coarctation of the abdominal aorta is a rare etiology of intermittent claudication and refractory hypertension. Treatment is complex and requires knowledge of several vascular reconstruction techniques. We report a case of aortic coarctation at the level of the renal arteries, describing its treatment and presenting a literature review. Female patient, 65 years old, with refractory hypertension since the age of 35, using five antihypertensive medications at maximum doses. Blood pressure was 260/180mmHg and she had disabling claudication (less than 20 meters). Computed tomography angiography showed a 4mm coarctation in the juxtarenal aorta, with circumferential calcification at the stenosis site, and tortuous infrarenal aorta. Hybrid repair was performed with an iliac-birenal bypass and implantation of an Advanta V12 stent at the stenosis site. The patient's postoperative course was satisfactory, she was free from claudication, and her blood pressure 60 days after surgery was 140/80mmHg, taking two antihypertensive medications.

Coarctação de aorta abdominal justarrenal associada à hipertensão renovascular e claudicação incapacitante: tratamento utilizando ponte ilíaco-birrenal e técnica "paving and cracking" / Coarctation of the abdominal aorta associated with renovascular hypertension and incapacitating claudication: repair with iliac-birenal bypass and paving and cracking technique

Resumo Coarctação da aorta abdominal é uma causa rara de claudicação de membros inferiores e hipertensão refratária. O tratamento é complexo e exige conhecimento de diversas técnicas de reconstrução vascular. Apresentamos um caso de coarctação ao nível das artérias renais, seu tratamento e revisão da literatura. Paciente feminina, 65 anos, com hipertensão refratária desde os 35 anos, utilizando cinco medicações anti-hipertensivas em dose máxima. Pressão arterial média de 260/180mmHg e claudicação incapacitante (menos de 20 metros) bilateral. Angiotomografia computadorizada demonstrou coarctação de aorta justarrenal de 4 mm de maior diâmetro, calcificação circunferencial no local da estenose e tortuosidade da aorta infrarrenal. Foi submetida a tratamento híbrido, com ponte ilíaco-birrenal e implante de stent Advanta V12 no local da estenose. A paciente evoluiu satisfatoriamente e, 60 dias depois da cirurgia, apresentava-se com uma pressão arterial de 140/80mmHg, em uso de apenas duas medicações anti-hipertensivas e sem claudicação.

Abstract Coarctation of the abdominal aorta is a rare etiology of intermittent claudication and refractory hypertension. Treatment is complex and requires knowledge of several vascular reconstruction techniques. We report a case of aortic coarctation at the level of the renal arteries, describing its treatment and presenting a literature review. Female patient, 65 years old, with refractory hypertension since the age of 35, using five antihypertensive medications at maximum doses. Blood pressure was 260/180mmHg and she had disabling claudication (less than 20 meters). Computed tomography angiography showed a 4mm coarctation in the juxtarenal aorta, with circumferential calcification at the stenosis site, and tortuous infrarenal aorta. Hybrid repair was performed with an iliac-birenal bypass and implantation of an Advanta V12 stent at the stenosis site. The patient's postoperative course was satisfactory, she was free from claudication, and her blood pressure 60 days after surgery was 140/80mmHg, taking two antihypertensive medications.

Short-term follow-up of embolization of hip synovitis.

BACKGROUND: Osteoarthritis (OA) is the most frequent joint disease, affecting 10% of men and 18% of women older than 60 years worldwide. Traditionally, treatment is based in pain management with joint replacement of end-stage disease. In this setting, transcatheter embolization has emerged as an alternative in reduction of pain in patients with OA. CASE PRESENTATION: A 77 years-old female presenting with two previous deep vein thrombosis and 10 years of hip pain. Magnetic resonance demonstrated a focal area of enhanced pericapsular signal near the superolateral margin of the acetabulum. Embolization of branches of the ascending branch of the lateral femoral circumflex artery was performed, with decrease of the pain and improvement in the image and her walking ability in a four-month follow-up. CONCLUSION: This case report have shown that embolization of hip synovitis is feasible with early clinical success, in tune with the findings of genicular and shoulder embolization. Studies with more patients and long-term results are necessary to corroborate this finding. LEVEL OF EVIDENCE: 4.

Prevalence of left iliac vein compression on computed tomography scans from a population.

BACKGROUND: May-Thurner syndrome (MTS) is defined as compression of the left iliac vein between the right iliac artery and the lumbar vertebral body in the presence of signs and symptoms of unilateral left chronic venous insufficiency. However, imaging findings of compression are not manifest in symptoms of the syndrome in all subjects. OBJECTIVES: To evaluate findings of compression in an asymptomatic population. METHODS: Computed tomography angiographies or venous phase computed tomographies were analyzed. Demographic data and reason for the exam were recorded. Vein diameter was measured at the site of greatest compression and distal of the compression and the ratio between the two diameters was calculated. RESULTS: From January to July of 2016, 590 computed tomography scans were analyzed (357 women and 233 men). Left iliac compression was found in 14.74% of patients. Patients with a left iliac diameter below the 5mm threshold had a mean diameter at the site of greatest iliac vein compression of 4.4 mm (range: 2.67 mm-4.97 mm). The ratio between the two measurements was < 0.5 in 30% of patients. CONCLUSIONS: Our study suggests that iliac vein compression is common among random patients who have had computed tomography for any other reason. This indicates that compression found on tomography images is not the only finding to consider when treating a patient.

Prevalência de compressão da veia ilíaca esquerda em imagens tomográficas de uma população / Prevalence of left iliac vein compression on computed tomography scans from a population

Resumo Contexto A síndrome de May-Thurner (SMT) é a compressão da veia ilíaca esquerda (VIE) entre a artéria ilíaca direita e o corpo vertebral associada à hipertensão venosa crônica unilateral no membro inferior esquerdo. Porém, o achado tomográfico da compressão não necessariamente se reflete em sintomas. Objetivos Avaliar o achado de compressão da veia ilíaca esquerda em tomografias realizadas por outros motivos. Métodos Angiotomografias ou tomografias computadorizadas (TCs) com fase venosa foram analisadas. Foram coletados os dados demográficos e o motivo do exame, quando presente, e foi analisada a relação do diâmetro da veia ilíaca esquerda no ponto de maior compressão com um ponto a montante. Resultados De janeiro a julho de 2016, 590 tomografias foram analisadas, sendo 357 de mulheres e 233 de homens. A compressão da VIE ocorreu em 87 (14,74%) pacientes, dos quais 74 (85,05%) eram mulheres e 13 (14,9%) homens. O diâmetro médio do ponto de maior compressão entre os pacientes que apresentavam VIE < 5 mm foi de 4,4 mm, variando de 2,67 mm a 4,97 mm. O diâmetro no ponto de maior compressão representou até metade do diâmetro na última imagem justaposta ao corpo vertebral (índice de 0,5) em 179 (30,3%) dos pacientes. Conclusões Nosso estudo sugere que a ocorrência de compressão da VIE em TC de pacientes aleatórios, sem conhecimento de insuficiência venosa crônica ou TVP em MIE, é comum. Isso mostra que o achado tomográfico de compressão não necessariamente resulta em sintomas e não deve ser a única razão para tratar um paciente.

Abstract Background May-Thurner syndrome (MTS) is defined as compression of the left iliac vein between the right iliac artery and the lumbar vertebral body in the presence of signs and symptoms of unilateral left chronic venous insufficiency. However, imaging findings of compression are not manifest in symptoms of the syndrome in all subjects. Objectives To evaluate findings of compression in an asymptomatic population. Methods Computed tomography angiographies or venous phase computed tomographies were analyzed. Demographic data and reason for the exam were recorded. Vein diameter was measured at the site of greatest compression and distal of the compression and the ratio between the two diameters was calculated. Results From January to July of 2016, 590 computed tomography scans were analyzed (357 women and 233 men). Left iliac compression was found in 14.74% of patients. Patients with a left iliac diameter below the 5mm threshold had a mean diameter at the site of greatest iliac vein compression of 4.4 mm (range: 2.67 mm-4.97 mm). The ratio between the two measurements was < 0.5 in 30% of patients. Conclusions Our study suggests that iliac vein compression is common among random patients who have had computed tomography for any other reason. This indicates that compression found on tomography images is not the only finding to consider when treating a patient.

Pelvic congestion syndrome and embolization of pelvic varicose veins.

Pelvic congestion syndrome (PGS) is defined as chronic pelvic pain for more than 6 months associated with perineal and vulvar varicose veins caused by reflux or obstruction in gonadal, gluteal, or parauterine veins. PGS accounts for 16-31% of cases of chronic pelvic pain, and is usually diagnosed in the third and fourth decades of life. Interest in this condition among vascular surgeons has been increasing over recent years because of its association with venous insufficiency of the lower limbs. Despite its significant prevalence, PGS is still poorly diagnosed in both gynecology and angiology offices. Therefore, in this article we review the etiology and diagnosis of this condition and the outcomes of the different types of treatment available.

Variação anatômica do tronco celíaco e do sistema arterial hepático: uma análise por exames de imagem / Anatomical variations of the celiac trunk and the hepatic arterial system: an imaging analysis

Introdução: As variações anatômicas das artérias hepáticas e do tronco celíaco são de grande importância para cirurgias laparoscópicas, transplantes hepáticos, intervenções radiológicas e tratamento de lesões abdominais. O grande aumento de intervenções minimamente invasivas deixou os atos cirúrgicos com menos espaço para o reconhecimento de estruturas anatômicas. Métodos: Foi realizado um estudo retrospectivo do banco de dados do Hospital São Vicente de Paulo durante o ano de 2016, analisando imagens abdominais de tomografia computadorizada com contraste e angiotomografias que envolvem a aorta abdominal e seus ramos ­ um total de 461 imagens foram analisadas. Resultados: Dos 461 pacientes analisados, 86,9% apresentaram a conformação usual do tronco celíaco ­ cuja anatômica é a origem tríplice com as artérias gástrica esquerda, esplênica e hepática comum e artéria mesentérica superior se originando sozinha da aorta abdominal. Dentre as anatomias anômalas (13%), o padrão mais comum desses ramos foi a presença em 4,5% de um tronco hepatomesentérico e um tronco gastroesplênico. No sistema arterial hepático a conformação mais prevalente foram as artérias hepáticas direita e esquerda sendo ramos da hepática próprias em 66,3%. Das alterações anatômicas (33,2%), as mais comuns foram a presença de uma artéria hepática esquerda acessória ramo da artéria gástrica esquerda (7,8%). Conclusão: Variações anatômicas do sistema arterial hepático e do tronco celíaco são prevalentes, podendo apresentar diversos arranjos organizacionais. (AU)

Introduction: Anatomical variations in the hepatic arteries and the celiac trunk are of great importance for laparoscopic surgeries, liver transplants, radiological interventions and treatment of abdominal injuries. A large increase in the number of minimally invasive interventions hampered the recognition of anatomical structures in surgical procedures. Methods: A retrospective study was performed using the 2016 São Vicente de Paulo Hospital database of contrast-enhanced abdominal computed tomography images and computed tomography angiographies showing the abdominal aorta and its branches. In total, 461 images were analyzed. Results: Of the 461 patients analyzed, 86.9% had usual conformation of the celiac trunk, which trifurcates into the left gastric artery, the common hepatic artery and the splenic artery, while the superior mesenteric artery originates alone from the abdominal aorta. Among the cases of anomalous anatomy (13%), the most common pattern in these branches was the presence of a hepatomesenteric trunk and a gastrosplenic trunk in 4.5%. In the hepatic arterial system, the most prevalent conformation was the right and left hepatic arteries being branches of the hepatic artery proper in 66.3%. Of all anatomical variations (33.2%), the most common were the presence of a left accessory hepatic artery of the left gastric artery (7.8%). Conclusion: Anatomical variations in the hepatic arterial system and the celiac trunk are common, having different structural arrangements. (AU)