Lipectomy as an alternative for superficialization of autologous AVF in obese patients: experience of a referral center in Amazon.

Background: The preferred vascular access for hemodialysis is a native arteriovenous fistula (AVF) because it offers the best results in the short and long terms, lower morbidity and mortality, and has additional advantages in relation to central venous catheters or arteriovenous grafts. However, obesity can present an additional challenge because of the barrier of subcutaneous cellular tissue covering the surface of the vein to be punctured. Objectives: The authors review their experience with excision of subcutaneous tissue (lipectomy) overlying upper arm cephalic vein arteriovenous fistulas in obese patients. Methods: Consecutive vascular access patients undergoing lipectomy for cannulation with difficult access because of vein depth were reviewed. Cephalic vein depth was measured by ultrasound in all cases. Results: Twenty-two patients were reviewed (15 men and 7 women), with a mean body mass index of 34.0 kg/m2 (range: 28-40 kg/m2). Mean age was 58.4 years. The mean preoperative vein depth of 7.9 mm (range: 7.0-10.0 mm) was reduced to 4.7 mm (range: 3.0-6.0 mm) (P 0.01). The mean follow-up period for patients was 13.2 months. Four patients were lost to follow-up and four died during the period due to causes unrelated to vascular access. Conclusions: Obesity should not be a limiting factor to creation of a native AVF, since lipectomy is a relatively simple option for superficialization, enabling functioning native and deep arteriovenous fistulas in obese patients.

Guidelines on vascular access for hemodialysis from the Brazilian Society of Angiology and Vascular Surgery.

Chronic kidney disease is a worldwide public health problem, and end-stage renal disease requires dialysis. Most patients requiring renal replacement therapy have to undergo hemodialysis. Therefore, vascular access is extremely important for the dialysis population, directly affecting the quality of life and the morbidity and mortality of this patient population. Since making, managing and salvaging of vascular accesses falls within the purview of the vascular surgeon, developing guideline to help specialists better manage vascular accesses for hemodialysis if of great importance. Thus, the objective of this guideline is to present a set of recommendations to guide decisions involved in the referral, evaluation, choice, surveillance and management of complications of vascular accesses for hemodialysis.

A doença renal crônica é um problema de saúde pública global e em seu estágio terminal está associada à necessidade de terapia dialítica. A grande maioria dos pacientes que necessitam realizar a terapia renal substitutiva, a fazem através da hemodiálise. Portanto, o acesso vascular é de extrema importância para a população dialítica, implicando diretamente na qualidade de vida e na morbimortalidade deste grupo de pacientes. Sendo a confecção, gerenciamento e resgate dos acessos vasculares uma das áreas de atuação do cirurgião vascular, é de grande importância a elaboração de uma diretriz que oriente o especialista no manejo mais adequado do acesso vascular para hemodiálise. Assim, o objetivo desta diretriz é apresentar um conjunto de recomendações para guiar as decisões na referenciação, avaliação, escolha, vigilância e gestão das complicações do acesso vascular para hemodiálise.

Traumatic aorta injuries in a rural area: late manifestations and review of therapeutic aspects.

Traumatic thoracic aortic injuries (TTAI) are associated with high rates of morbidity and mortality. They are classified according to the extent of damage and computed tomography angiography has the highest sensitivity and specificity for identifying the degree of injury and potential associated lesions. Treatment strategies for TTAI are based on the type and extent of injury and associated lesions. The patient's degree of stability can also help to define the choice of treatment, which can be conventional or endovascular surgery (EVAR) or even conservative management in selected cases. Among patients with adequate vascular anatomy, endovascular surgery is associated with better survival and fewer risks. The objective of this article is to describe a series of four cases followed up at a tertiary service in a Brazilian state that has few centers that provide high complexity care. Endovascular therapy was employed as the preferred method. All four patients had favorable outcomes, with no complications up to discharge, and are currently in outpatient follow-up.

Epidemiological profile of surgical treatment of varicose veins in Brazil from 2010 to 2020.

Background: Varicose veins have become more common over recent years and in the most serious cases surgical treatment is necessary to resolve patients' clinical status. Despite their importance, there are no epidemiological studies that cover the whole of Brazil, showing how surgery to correct varicose veins conducted by the Unified Health System (SUS) is distributed in the country. Objectives: To describe the ecological profile of surgical treatment to correct varicose veins in Brazil from 2010 to 2020. Methods: This is a descriptive-analytical study of data obtained from the SUS Hospital Information System. These data were tabulated and categorized by state, region, type of procedure, and year. BioEstat 5.3 was used to conduct chi-square statistical tests with a 95% confidence interval and significance cutoff of p <0.05. Results: From 2010 to 2020, 755,752 surgical operations to treat varicose veins were conducted; 292,538 were unilateral (38.71%) and 463,214 (61.29%) were bilateral. Of these, 418,791 (55.41%) procedures were performed in the Southeast region, followed by 180,689 (23.91%) in the South region. A total of 40 deaths were registered in connection with these procedures during the period, 26 of which (65%) were associated with bilateral surgery and the majority of which occurred in the Southeast (24 deaths). Conclusions: It was observed that the majority of procedures are performed in the Southeast and South regions, and that bilateral elective surgery is the most prevalent.

Vascular surgery in the most populous state in the Amazon: socio-professional profile and aspirations of the specialty.

BACKGROUND: There is a dearth of studies conducted to understand the socio-professional profile of the vascular surgery specialty and the population demands of specific regions, which are needed to support creation of care policies and direct infrastructure improvements in healthcare. OBJECTIVES: The purpose of this study was to describe the socio-professional profile of vascular surgeons in the state of Pará, Brazil, to guide creation of tools for professional improvement. METHODS: A cross-sectional, self-report survey was conducted in Pará using a questionnaire comprising 30 questions covering six main topics. RESULTS: All vascular surgeons actively practicing in the state participated in this study. The total number of specialists was 59, with 71.2% working in the greater Belém area and 16.9% exclusively practicing in the interior of the state. The mean age of these professionals was 48 ± 11.1 years, 86.4% of respondents were men, 64.4% of surgeons had completed medical residency, and 96.6% (n=57) of the surgeons would like to improve their skills in venous surgery, echo-guided vascular access, and endovascular surgery. The method of professional improvement of greatest interest was simulation courses (hands-on), endorsed by 93% of the participants. CONCLUSIONS: Pará has 59 vascular surgeons. These professionals mainly work in the greater Belém (71.2%), in hospitals (100%) or in private clinics or offices (94.9%), performing a wide range of procedures, including venous and arterial surgery, amputations, and provision of hemodialysis access. More than 90% of these surgeons were satisfied professionally and reported that they would choose the specialty again. However, 22% had a pessimistic view of the specialty's future. The vast majority of professionals (96.6%) consider that training or a continuing education program are necessary.

CONTEXTO: Há uma falta de estudos necessários para entender o perfil socioprofissional da especialidade e as demandas específicas da população de uma região específica, a fim de subsidiar a criação de políticas assistenciais e a melhoria na infraestrutura da assistência à saúde. OBJETIVOS: O objetivo deste estudo foi descrever o perfil socioprofissional de cirurgiões vasculares no Pará para orientar a criação de ferramentas de melhoria profissional. MÉTODOS: Foi realizado um levantamento transversal no Pará utilizando um questionário com 30 questões que envolvia seis temas principais. RESULTADOS: Todos os cirurgiões vasculares ativos participaram deste estudo. O número total de especialistas foi de 59, dos quais 71,2% trabalhavam na grande Belém e 16,9% exclusivamente no interior do estado. A idade média dos profissionais foi de 48 ± 11,1 anos, e 86,4% dos entrevistados eram homens. Além disso, 64,4% dos cirurgiões haviam completado a residência médica, e 96,6% (n = 57) deles gostariam de ter melhorias em cirurgia venosa, acesso vascular ecoguiado e cirurgia endovascular. As áreas de maior interesse para melhorias são cursos de simulação (práticos), com 93% dos participantes interessados. CONCLUSÕES: O Pará tem 59 cirurgiões vasculares, os quais trabalham principalmente na grande Belém (71,2%) em hospitais (100%) ou em clínicas privadas ou consultórios (94,9%) e realizam uma ampla gama de procedimentos, incluindo cirurgias venosas e arteriais, amputações e acessos para hemodiálise. Mais de 90% dos cirurgiões estavam satisfeitos e relataram que escolheriam a especialidade novamente; entretanto, 22% tinham uma visão pessimista do futuro da especialidade. A grande maioria dos profissionais (96,6%) considera a necessidade de qualificação ou de um programa de educação continuada.

Incidental cardiovascular findings on chest CT scans requested for suspected COVID-19.

BACKGROUND: Computed tomography scans of the chest are often requested as a complementary examination to investigate a clinical suspicion of pulmonary disease caused by the novel coronavirus 19 (COVID-19). OBJECTIVES: Our objective was to analyze the prevalence of incidental cardiovascular findings on chest CT scans requested to assess radiological signs suggestive of COVID-19 infection. METHODS: This cross-sectional, descriptive, and retrospective study reviewed 1,444 chest tomographies conducted in the Radiology department of the Hospital de Clínicas Gaspar Vianna, from March 1 to July 30, 2020, describing the prevalence of images suggestive of viral pneumonia by COVID-19 and incidental pulmonary and cardiovascular findings. RESULTS: The mean age of the patients was 50.6 ± 16.4 years and female sex was more frequent. Computed tomography without contrast was the most frequently used method (97.2%). Aortic and coronary wall calcification and cardiomegaly were the most prevalent cardiovascular findings. CT angiography revealed aortic aneurysms (9.7%), aortic dissection (7.3%) and thoracic aortic ulcers (2.4%). CONCLUSIONS: Incidental cardiovascular findings occurred in about half of the chest CT scans of patients with suspected COVID-19, especially aortic calcifications, cardiomegaly, and coronary calcification.

Novel Porcine Kidney-Based Microsurgery Training Model for Developing Basic to Advanced Microsurgical Skills.

BACKGROUND: Microsurgery training is critical to the practice of microvascular procedures in many surgical areas. However, even simple procedures require different levels of complex skills. Therefore, simulation-based surgical training, mainly in the area of vascular anastomosis, is of great importance. In this paper, we present a new microsurgery training model for the development of basic to advanced microsurgical skills. METHODS: Porcine kidneys were purchased from a legal butchery slaughterhouse. First, kidneys were washed with water to remove blood and clots inside vessels. Then, dissection was performed throughout the vascular pedicle from the renal arteries to the segmentary branches. Finally, the longitudinal sectioning of the kidney parenchyma was performed to expose the vessels necessary for training. Sixty end-to-end anastomoses were performed. Specific instruments and materials were used to perform anastomoses and dissections with magnification by a video system. We evaluated the diameter of vessels, time to perform anastomosis, and patency of anastomosis. RESULTS: There was no great anatomical variation among the porcine kidneys. The total length for dissection training was 25.80 ± 7.44 cm using the arterial and venous vessel. The average time to perform arterial anastomoses was 23.79 ± 4.55 minutes. For vessel diameters of ≤ 3, 4 to 6, and 7 to 10 mm, the average procedure times were 27.68 ± 3.39, 22.92 ± 4.12, and 20.77 ± 3.44 minutes, respectively. Regarding venous anastomosis, the average duration of the procedure was 26.17 ± 4.80 minutes, including durations of 31.61 ± 3.86, 25.66 ± 4.19, and 21.24 ± 3.79 minutes for vessel diameters of ≤ 7, 8 to 10, and >10 mm, respectively. Positive patency was achieved in all surgeries. CONCLUSION: The porcine kidney provides an inexpensive and convenient biological model for modeling microanastomosis with high fidelity to vascular structures.

Superselective renal artery embolization for treatment of urological hemorrhage after partial nephrectomy in a solitary kidney.

Embolization is a well-known and accepted form of treatment for bleeding caused by a multitude of renal procedures. We present a case of a 66-year-old woman who had a history of left nephrectomy for clear cell carcinoma seven years previously and now presented with a 6 cm tumor involving the solitary kidney. She underwent partial laparoscopic nephrectomy with removal of the tumor on the right kidney. In the immediate postoperative period she had important and persistent hematuria associated with tachycardia, hypotension, and lumbar pain. After showing signs of hemodynamic instability, she was taken to the catheter laboratory where selective angiography of the right kidney was performed. Superselective embolization with controlled release of fibrous microcoils was performed. The superselective renal embolization technique performed on an emergency basis to control hemorrhage after a urological procedure is effective and achieves lasting resolution of symptoms.

A embolização é uma forma bem conhecida e aceita de tratamento para sangramento de inúmeros procedimentos renais. Apresentamos o caso de uma mulher de 66 anos de idade com história de nefrectomia esquerda por carcinoma de células claras havia 7 anos, que desta vez apresentava rim único afetado por um tumor de 6 cm. Ela foi submetida a nefrectomia parcial videolaparoscópica com remoção do tumor no rim direito. Apresentou, no pós-operatório imediato, hematúria importante e persistente associada a taquicardia, hipotensão e dor lombar. A paciente apresentou sinais de instabilidade hemodinâmica e foi levada ao setor de hemodinâmica, onde foi realizada angiografia seletiva do rim direito. Foi localizado foco sangrante, sendo então realizada embolização superseletiva com liberação controlada de microcomolas. A técnica de embolização renal superseletiva realizada em caráter de emergência para controlar a hemorragia após um procedimento urológico é uma solução eficaz, minimamente invasiva e segura para controle dos sintomas.

Fracture of a popliteal nitinol stent and pseudoaneurysm: a case report and review of the literature.

There is a lack of reports onr stent fracture with pseudoaneurysm formation in the femoropopliteal artery, which can cause restenosis or occlusion of the treated arterial segment. We present a case of a large pseudoaneurysm of the popliteal artery that was observed 18 months after popliteal stenting using a self-expandable nitinol stent. We describe an endovascular approach to overcome this severe complication. Stent fractures are an often overlooked complication of femoropopliteal stenting and can be associated with serious diseases. The popliteal artery was successfully treated using self-expandable Viabahn endoprosthesis.

Bilateral compartment syndrome of the lower limbs after urological surgery in the lithotomy position: a clinical case.

Acute compartment syndrome of the lower extremities after urological surgery in the lithotomy position is a rare but potentially devastating clinical and medicolegal problem. We report the case of a 67-year-old male who underwent laparoscopic prostatectomy surgery to treat cancer, spending 180 minutes in surgery. Postoperatively, the patient developed acute compartment syndrome of both legs, needing emergency bilateral four-compartment fasciotomies, with repeated returns to the operating room for second-look procedures. The patient also exhibited delayed wound closure. He regained full function within 6 months, returning to unimpaired baseline activity levels. This report aims to highlight the importance of preoperative awareness of this severe complication which, in conjunction with early recognition and immediate surgical management, may mitigate long-term adverse sequelae and improve postoperative outcomes.

A síndrome compartimental aguda dos membros inferiores após cirurgia urológica na posição de litotomia é um problema clínico e médico-legal raro, mas potencialmente devastador. Reportamos o caso de um homem de 67 anos submetido a uma prostatectomia laparoscópica por câncer. A cirurgia durou 180 min. No pós-operatório, o paciente desenvolveu síndrome compartimental aguda de ambos os membros inferiores, necessitando de fasciotomias de urgência, com retornos repetidos à sala de cirurgia para procedimentos adicionais. O paciente também apresentou fechamento tardio da ferida. Ele recuperou a função completa dentro de 6 meses e retornou a um nível de atividade basal irrestrito. Este artigo tem a importância de ressaltar a consciência pré-operatória desta grave complicação que, em conjunto com o reconhecimento precoce e o tratamento cirúrgico imediato, pode mitigar sequelas adversas em longo prazo e melhorar os resultados pós-operatórios.

Preferential use of nonreversed vein grafts in above-knee femoropopliteal bypasses for critical ischemia: midterm outcome.

We evaluated nonreversed vein grafts in above-knee bypasses for chronic critical limb ischemia in a retrospective study with intention-to-treat analysis in patients who underwent above-knee bypass grafting. During a 4-year period, 51 patients (men, 32; women, 19; mean age = 66 years) with 53 critically ischemic lower extremities underwent above-knee femoropopliteal bypass grafting. The follow-up evaluation consisted of clinical examination, assessment of the ankle-brachial systolic blood pressure index, and, whenever necessary, duplex scanning. Three (5.7%) deaths occurred within 30 days, two from myocardial infarction and one from an undetermined cause. The 2-year cumulative success rate was 82.5 +/- 9.6% for primary patency, 84.6 +/- 8.9% for secondary patency, 90.1 +/- 7.3% for tertiary patency, 86.9 +/- 7.6% for limb salvage, 77.7 +/- 8.4% for survival, 68.0 +/- 11.1% for composite patency, and 68.4 +/- 9.3% for amputation-free survival; the corresponding estimates for vein grafts alone were 86.6 +/- 9.2%, 88.9 +/- 8.6%, 89.0 +/- 8.5%, 88.1 +/- 8.1%, 81.1 +/- 9.1, 76.8 +/- 11.1%, and 72.6 +/- 10.2%. Three prosthetic grafts failed and were replaced with an arm vein graft. Nonreversed vein bypass grafts in above-knee revascularization of critically ischemic limbs are justified.