ABSTRACT
This study retrospectively examined the hemodynamic effects of passive leg raising (PLR) in mechanically ventilated patients during fluid removal before spontaneous breathing trials. In previous studies, we noticed varying cardiac responses after PLR completion, particularly in positive tests. Using a bioreactance monitor, we recorded and analyzed hemodynamic parameters, including stroke volume and cardiac index (CI), before and after PLR in post-acute ICU patients. We included 27 patients who underwent 60 PLR procedures. In preload-unresponsive patients, no significant CI changes were observed (CI_t-6 = 3.7 [2.6; 4.7] mL/min/m2 vs. CI_t9 = 3.3 [2.5; 3.4] mL/min/m2; p = 0.306), while in preload-responsive patients, two distinct CI response types to PLR were identified: a transient peak with immediate return to baseline (CI_t-6 = 2.7 [2.5; 3.1] mL/min/m2 vs. 3.3 [2.6; 3.8] L/min/m2; p = 0.119) and a sustained CI elevation lasting beyond the PLR maneuver (CI_t-6 = 2.8 [2.3; 2.9] L/min/m2 vs. 3.3 [2.8; 3.9] ml/min/m2; p = 0.034). The latter was particularly noted when ΔCI during PLR exceeded 25%. Our findings suggest that in certain preload-responsive patients, PLR can induce a more sustained increase in CI, indicating a possible persistent hemodynamic effect. This effect could be due to a combination of autotransfusion and sympathetic activation affecting venous return and vascular tone. Further research in larger cohorts and more comprehensive hemodynamic assessments are warranted to validate these observations and elucidate the possible underlying mechanisms.The Fluid unLoading On Weaning (FLOW) study was prospectively registered under the ID NCT04496583 on 2020-07-29 at ClinicalTrials.gov.
Subject(s)
Cardiac Output , Hemodynamics , Leg , Respiration, Artificial , Stroke Volume , Humans , Male , Female , Middle Aged , Retrospective Studies , Leg/blood supply , Aged , Respiration, Artificial/methods , Stroke Volume/physiology , Intensive Care Units , Heart/physiology , Monitoring, Physiologic/methods , AdultSubject(s)
Carcinoma, Basal Cell , Extracellular Matrix , Skin Neoplasms , Venous Insufficiency , Humans , Venous Insufficiency/physiopathology , Venous Insufficiency/pathology , Venous Insufficiency/complications , Skin Neoplasms/pathology , Extracellular Matrix/pathology , Extracellular Matrix/metabolism , Carcinoma, Basal Cell/pathology , Male , Female , Leg/blood supply , Chronic Disease , Aged , Middle AgedABSTRACT
Telangiectasias is most prevalent on the lower limbs and has been estimated to manifest in 40%-90% of the population. Treatments for telangiectasias include sclerotherapy, laser therapy, intense pulsed light treatment, microphlebectomy, and thermocoagulation. Cryo-Laser & Cryo-Sclerotherapy (CLaCS) effectively combines thermal and injection sclerotherapy. In this treatment, unwanted veins are targeted by a transdermal laser and immediately receive injection sclerotherapy. During the whole procedure, an air-cooling device (Cryo) blows onto the surrounding skin and tissue to prevent skin burn. Here, we present a case report of a challenging telangiectasias treated with ClaCS.
Subject(s)
Augmented Reality , Laser Therapy , Telangiectasis , Humans , Leg/blood supply , Follow-Up Studies , Lower Extremity , Sclerotherapy/methods , Telangiectasis/surgery , Treatment OutcomeABSTRACT
Phlegmasia cerulea dolens, a rare and potentially fatal complication of acute deep vein thrombosis, is characterized by substantial edema, intense pain, and cyanosis. Phlegmasia cerulea dolens may compromise limb perfusion and lead to acute ischemia, gangrene, amputation, and death. We present the case of a 61-year-old woman with a history of breast cancer who had signs and symptoms of phlegmasia cerulea dolens in her left leg. She was treated promptly with open surgical thrombectomy and sequential distal compression with use of an Esmarch bandage to ensure complete thrombus extraction. These techniques restored venous flow and saved her leg. Open surgical thrombectomy should be considered in the presence of limb-threatening acute deep vein thrombosis presenting as phlegmasia cerulea dolens.
Subject(s)
Neoplasms , Venous Thrombosis , Female , Humans , Leg/blood supply , Middle Aged , Thrombectomy/methods , Vascular Surgical Procedures , Venous Thrombosis/diagnosis , Venous Thrombosis/etiology , Venous Thrombosis/surgeryABSTRACT
INTRODUCCIÓN: El síndrome compartimental es una complicación infrecuente pero severa que puede aparecer ante una posición de litotomía prolongada y el uso de perneras. OBJETIVO: Presentar un caso de síndrome compartimental bilateral tras posición de litotomía prolongada asociada con el uso de perneras. MATERIAL Y MÉTODOS: Paciente varón de 43 años sometido a una cirugía urológica en posición habitual de litotomía durante un periodo de 6 horas. A las 2 horas de finalizar la cirugía, el paciente presentó dolor intenso y endurecimiento de compartimento anterior y lateral de ambas piernas, junto con una elevación de la creatina quinasa sérica (valor inicial de 109 U/L que se elevó hasta 7.689 U/L a las 12 horas) y una imposibilidad para la flexión dorsal pasiva de ambos tobillos. El paciente no sentía dolor en el resto de los compartimentos. RESULTADOS: Ante la sospecha de un síndrome compartimental anterolateral, se realizó fasciotomía bilateral urgente, y se observó una disminución de la perfusión muscular y mejoría de la misma tras apertura de la fascia. Se realizaron curas periódicas cada 48 horas, y se observó viabilidad del tejido hasta su cierre definitivo a los 4 días. A las 2 semanas, el paciente presentó fatiga ligera para la deambulación sin ayuda, con tumefacción en el compartimento lateral de ambas piernas. A los 10 meses de evolución, el paciente caminaba sin ayuda y con función muscular completa. CONCLUSIONES: El conocimiento de la asociación del síndrome compartimental y la cirugía laparoscópica prolongada es esencial para un diagnóstico precoz y un tratamiento quirúrgico inmediato, para evitar graves secuelas. Los buenos resultados de nuestro paciente se deben a la rápida actuación, ya que normalmente se suele demorar. Para evitar su aparición o disminuir su incidencia, la posición de litotomía debería limitarse a aquellos momentos de la cirugía en los que sea imprescindible, modificando la posición de las piernas cada dos horas en caso de cirugías prolongadas, para prevenir dicha complicación.
Compartment syndrome is a rare but severe complication resulting from a prolonged lithotomy position and the use of leg loops. PURPOSE: To present a case of bilateral compartment syndrome after prolonged lithotomy position associated with the use of leg loops. METHODS: A 43-year-old man underwent urological surgery in the usual lithotomy position for a 6-hour period. Two hours after the end of the surgery, the patient presented severe pain and stiffening of the anterior and lateral compartments of both legs, elevated serum creatine kinase levels (the baseline value of 109 U/L increased to 7,689 U/L at 12 hours), and inability for passive dorsiflexion of both ankles. The patient reported no pain in the other compartments. RESULTS: Suspicion of an anterolateral compartment syndrome resulted in an urgent bilateral fasciotomy; muscle perfusion was decreased, and it improved after fascial opening. Dressings were changed every 48 hours, and tissue viability was observed until the final closure at 4 days. At two weeks, the patient presented slight fatigue when walking with no assistance, in addition to swelling in the lateral compartment of both legs. Ten months after surgery, the patient walked with no assistance and with complete muscle function. CONCLUSION: Knowledge of the association between compartment syndrome and prolonged laparoscopic surgery is essential for an early diagnosis and immediate surgical treatment to avoid serious sequelae. In our patient, the good outcomes resulted from quick action, since diagnosis is often delayed. Limiting the lithotomy position to those surgical moments in which it is essential and changing the position of the legs every 2 hours during prolonged procedures can reduce the occurrence and incidence of compartment syndrome, preventing this complication.
Subject(s)
Humans , Male , Adult , Compartment Syndromes/surgery , Fasciotomy/methods , Urologic Surgical Procedures/adverse effects , Supine Position , Leg/blood supplyABSTRACT
Peripheral vascular injuries are uncommon in civilian trauma but can threaten the patient's life or the viability of the limb. The definitive control of the vascular injury represents a surgical challenge, especially if the patient is hemodynamically unstable. This article proposes the management of peripheral vascular trauma following damage control surgery principles. It is essential to rapidly identify vascular injury signs and perform temporary bleeding control maneuvers. The surgical approaches according to the anatomical injured region should be selected. We propose two novel approaches to access the axillary and popliteal zones. The priority should be to reestablish limb perfusion via primary repair or damage control techniques (vascular shunt or endovascular approach). Major vascular surgeries should be managed post-operatively in the intensive care unit, which will allow correction of physiological derangement and identification of those developing compartmental syndrome. All permanent or temporary vascular procedures should be followed by a definitive repair within the first 8 hours. An early diagnosis and opportune intervention are fundamental to preserve the function and perfusion of the extremity.
El trauma vascular periférico no es común en el contexto civil, pero representa una amenaza para la vida del paciente o de la extremidad. El control definitivo de la lesión vascular representa un desafío quirúrgico, especialmente en pacientes con inestabilidad hemodinámica. Este artículo describe la propuesta de manejo del trauma vascular periférico de acuerdo con los principios de la cirugía de control de daños. Se debe identificar los signos sugestivos de lesión vascular y realizar oportunamente maniobras temporales para el control del sangrado. Se debe elegir el abordaje quirúrgico dependiendo del área anatómica lesionada. Se proponen dos nuevas incisiones para acceder a la región axilar y poplítea. La prioridad es restablecer la perfusión de la extremidad mediante el reparo primario o técnicas de control de daños (shunt vascular o abordaje endovascular). Los pacientes sometidos a cirugías vasculares mayores deben ser manejados postoperatoriamente en la unidad de cuidados intensivos para corregir las alteraciones fisiológicas e identificar aquellos que desarrollen un síndrome compartimental. Todos los procedimientos vasculares permanentes o temporales deben contar con un reparo definitivo en las primeras 8 horas. El diagnóstico temprano e intervención oportuna son fundamentales para salvaguardar la perfusión y funcionalidad de la extremidad.
Subject(s)
Arm/blood supply , Hemorrhage/therapy , Leg/blood supply , Vascular System Injuries/surgery , Axillary Artery/injuries , Axillary Artery/surgery , Brachial Artery/injuries , Brachial Artery/surgery , Compartment Syndromes/diagnosis , Consensus , Femoral Artery/injuries , Femoral Artery/surgery , Hemostatic Techniques , Humans , Medical Illustration , Popliteal Artery/injuries , Popliteal Artery/surgery , Postoperative Complications/etiology , Symptom Assessment , Vascular Surgical Procedures , Vascular System Injuries/classification , Vascular System Injuries/diagnosis , Vascular System Injuries/epidemiologySubject(s)
Leg/blood supply , Thrombophlebitis/diagnostic imaging , Thrombophlebitis/etiology , Ultrasonography, Doppler/methods , Venous Thrombosis/diagnostic imaging , Diagnostic Imaging , Fatal Outcome , Femoral Vein/diagnostic imaging , Humans , Iliac Vein/diagnostic imaging , Male , Middle Aged , NecrosisABSTRACT
BACKGROUND: Bypass surgery using a large saphenous vein graft, or another autologous venous graft, is a well-recognised treatment option for managing peripheral arterial disease of the lower limb, including chronic limb-threatening ischaemia (CLTI) and intermittent claudication, peripheral limb aneurysms, and major limb arterial trauma. Bypass surgery has good results in terms of limb preservation rates and long-term graft patency but is limited by the possibility of vein graft failure due to stenoses of the graft. Detection of stenoses through clinical and ultrasonographic surveillance, followed by treatment, is used to avoid graft occlusion. The conventional approach to treatment of patients with graft stenosis following infrainguinal bypass consists of open surgical repair, which usually is performed under general anaesthesia. Endoluminal treatment with angioplasty is less invasive and uses local anaesthesia. Both methods aim to improve blood flow to the limb. OBJECTIVES: To assess the effectiveness of endoluminal interventions versus surgical intervention for people with vein graft stenosis following infrainguinal bypass. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov to 25 August 2020. SELECTION CRITERIA: We aimed to include all published and unpublished randomised controlled trials (RCTs) that compared endoluminal interventions versus surgical intervention for people with vein graft stenosis following infrainguinal bypass. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed all identified studies for potential inclusion in the review. We aimed to use standard methodological procedures in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. The main outcomes of interest were primary patency, primary assisted patency, and all-cause mortality. MAIN RESULTS: We identified no RCTs that met the inclusion criteria for this review. AUTHORS' CONCLUSIONS: We found no RCTs that compared endoluminal interventions versus surgical intervention for stenosis in vein grafts following infrainguinal bypass. Currently, there is no high-certainty evidence to support the use of one type of intervention over another. High-quality studies are needed to provide evidence on managing vein graft stenosis following infrainguinal bypass.
Subject(s)
Angioplasty/methods , Graft Occlusion, Vascular/therapy , Leg/blood supply , Peripheral Arterial Disease/surgery , Aneurysm/surgery , Constriction, Pathologic/therapy , Humans , Intermittent Claudication/surgery , Ischemia/surgery , Saphenous Vein/transplantation , Vascular PatencyABSTRACT
Resumo Contexto A insuficiência venosa crônica é uma doença de alta prevalência mundial, podendo chegar a até 80% da população. Sua incidência aumenta com a idade e é mais frequente no sexo feminino. Das opções terapêuticas, destaca-se a terapia compressiva, sendo a principal o uso de meia elástica de compressão graduada, considerado o tratamento básico para a insuficiência venosa crônica independentemente da classificação clínica do paciente. Na prática clínica, o resultado da terapia é prejudicado pela não adesão ao uso da meia. Objetivos Avaliar a taxa de adesão ao uso da meia elástica de compressão graduada, assim como compreender a problemática da não aderência ao tratamento. Métodos Estudo observacional transversal, realizado entre junho de 2017 até janeiro de 2019, mediante aplicação de questionário aos pacientes em ambulatório de cirurgia vascular do Sistema Único de Saúde (SUS), em um hospital-escola, em Curitiba, no estado do Paraná (PR). Os dados foram analisados com o programa computacional IBM SPSS Statistics v.20.0. Resultados Foram analisados 240 pacientes. A média de idade foi de 57,5±12,9 (22-86); 84,2% eram do sexo feminino. Do total de pacientes analisados, 106 (44,2%) não aderiram ao uso das meias. As justificativas para o não uso foram: questão financeira, dor, desconhecimento da necessidade, calor e outras. Conclusões A taxa de adesão encontrada no presente estudo foi de 55,8%, e o principal motivo para o não uso foi a questão financeira.
Abstract Background Chronic venous insufficiency (CVI) is a pathology of great importance due to its high worldwide prevalence, affecting up to 80% of the population. Its incidence increases with age and is more frequent in females. One of the most important treatment options is compression therapy and the main method employed is wearing graduated compression stockings, which is considered the basic treatment for CVI regardless of the patient's clinical classification. In clinical practice, treatment outcomes are impaired by patients not wearing the stockings properly. Objectives To analyze the rate of adherence to wearing graduated compression stockings and to understand the problem of treatment non-adherence. Methods Cross-sectional observational study conducted from June 2017 to January 2019, based on administration of questionnaires to patients at a SUS vascular surgery clinic at a teaching hospital, in Curitiba, PR, Brazil. Data were analyzed using the IBM SPSS Statistics v.20.0 computer program. Results 240 patients were analyzed. Mean age was 57.5 ± 12.9 (22 - 86) and 84.2% of the sample were female. 106 of the 240 patients analyzed (44.2%) were non-adherent with wearing compression stockings. Reasons for not wearing the stockings were: financial; pain; ignorance of the need to wear them; heat; and others. Conclusions The adherence rate observed in the present study was 55.8% and the most prevalent reason for not wearing stockings was financial.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Young Adult , Venous Insufficiency/therapy , Unified Health System , Stockings, Compression , Venous Insufficiency/prevention & control , Cross-Sectional Studies , Treatment Adherence and Compliance , Leg/blood supplyABSTRACT
OBJECTIVE: Endovascular treatment for femoropopliteal arterial disease has made revascularization procedures less invasive, but the self-expanding stents used can suffer great wear in arteries with extreme mobility. To evaluate the prevalence of fractures in stents implanted in the femoropopliteal segment, to identify predisposing factors and consequences on arterial patency. METHOD: between March and June 2019, thirty patients previously operated for femoropopliteal obstruction underwent stent X-rays in anteroposterior and lateral views to detect fractures and Doppler to analyze arterial patency. RESULTS: we observed 12 cases with fractures (33.3%): 1 type I (2.8%), 3 type II (8.3%), 5 type III (13.9%), 3 type IV (8.3%) and no type V. According to the TASC II we had 1 in group B (8.3%), 6 in group C (50%) and 5 in group D (41.6%) p <0.004. The number of stents per limb was 3.1 (± 1.3) in cases of fracture versus 2.3 (± 1.3) in cases without fracture (p = 0.08). The extension was 274.17mm (± 100.94) in cases of fracture and 230.83mm (± 135.44) in cases without fracture (p = 0.29). On Doppler we had: 17 patients (47.2%) without stenosis, 9 patients (25%) with stenosis> 50% and 10 patients (27.8%) with occlusion (p = 0.37). There was no correlation between fracture and arterial obstruction (p = 0.33). CONCLUSION: stent fractures are a frequent finding in the femoropopliteal area (33.3%), being more prevalent in cases of more advanced disease (C and D). There was no association between the finding of fracture and arterial obstruction.
Subject(s)
Endovascular Procedures/methods , Peripheral Arterial Disease , Peripheral Vascular Diseases/therapy , Popliteal Artery , Prosthesis Failure , Stents , Ultrasonography, Doppler, Color/methods , Humans , Leg/blood supply , Peripheral Vascular Diseases/diagnostic imaging , Prevalence , Prosthesis Design , Retrospective Studies , Risk Factors , Treatment Outcome , Vascular PatencyABSTRACT
BACKGROUND: The main risk factor associated with basal cell carcinomas (BCCs) is believed to be exposure to ultraviolet radiation (UVR). In the case of lower limb BCC, the frequency is higher in women, possibly because of greater exposure of the leg to UVR. Chronic venous insufficiency (CVI), also more common in women, may have some association with leg BCCs. METHODS: We retrospectively evaluated the histopathological features of leg BCCs removed between 1993 and 2017 in a tertiary referral center. The patients' clinical data were obtained from medical records, considering, in particular, CVI. RESULTS: We selected 149 patients with leg BCCs, predominately occurring in elderly Caucasian women. Of those, 71 had a clinical diagnosis of CVI in whom the clinical tumor size and frequency of recurrences were significantly higher than patients without CVI. There was an association between clinical diagnosis of CVI and histological findings of (1) follicular induction in epidermis and (2) distal sweat duct hyperplasia. CONCLUSIONS: CVI, besides the already known UVR exposure, is probably associated with leg BCCs and may determine a worse BCC course.
Subject(s)
Carcinoma, Basal Cell/etiology , Leg/blood supply , Skin Neoplasms/etiology , Venous Insufficiency/complications , Adult , Aged , Aged, 80 and over , Carcinoma, Basal Cell/pathology , Carcinoma, Basal Cell/surgery , Chronic Disease , Humans , Middle Aged , Neoplasm Recurrence, Local , Retrospective Studies , Risk Factors , Sex Factors , Skin Neoplasms/pathology , Skin Neoplasms/surgery , Time Factors , Treatment Outcome , Tumor Burden , Venous Insufficiency/diagnosisABSTRACT
BACKGROUND: Chronic venous insufficiency (CVI) causes pathophysiological changes in the lower-limb muscles, particularly the calf muscles, and limits ankle range of motion (ROM). These changes reduce functional activities and decrease quality of life (QOL). Although several studies have shown the benefits of exercise (strengthening the calf muscles to improve calf-muscle pumping and QOL) in patients with CVI, few studies are randomized controlled trials. This has led to a weak indication of exercise for the treatment of patients with CVI. The aim of this study is to analyze the effects of a supervised exercise program to improve calf-muscle endurance as well as QOL in patients with CVI. METHODS/DESIGN: This is an evaluator-blind, randomized clinical trial with an 8-week duration and a follow-up evaluation at week 16. A pilot study with subjects with a CVI diagnosis will be performed to calculate sample size. The participants will be randomly allocated (1:1) into a treatment or a control group (usual care/no intervention). The treatment intervention consists of a bi-weekly supervised exercise program of the lower limbs that will include aerobic training, strengthening and cardiovascular exercises. The participants from both groups will participate in a health education lecture. Primary outcomes are changes in calf-muscle endurance and QOL score. Secondary outcomes are changes in exercise capacity, ankle ROM, electrical muscle activity and cardiac output. The first statistical comparison will be performed after 8 weeks' intervention. DISCUSSION: Patients with CVI may have an impaired calf-muscle pump and decreased exercise capacity. A randomized controlled trial evaluating a supervised exercise program should provide much needed information on the management of CVI to promote health and independence. TRIAL REGISTRATION: This study was registered on the Brazilian Clinical Trials Database (REBEC) (RBR-57xtk7). The results will be disseminated at scientific events, presentations, and publications in peer-reviewed journals.
Subject(s)
Exercise Therapy , Leg/blood supply , Muscle, Skeletal/blood supply , Venous Insufficiency/therapy , Ankle Joint/physiopathology , Brazil , Chronic Disease , Humans , Muscle, Skeletal/physiopathology , Pilot Projects , Plethysmography , Quality of Life , Randomized Controlled Trials as Topic , Range of Motion, Articular , Treatment Outcome , Venous Insufficiency/physiopathologyABSTRACT
OBJECTIVE: To evaluate the effects of a low-load resistance training program associated with partial blood-flow restriction in patients with rheumatoid arthritis (RA). METHODS: Forty-eight women with RA were randomized into 1 of 3 groups: high-load resistance training (HL-RT; 70% 1 repetition maximum [1RM]), low-load resistance training (30% 1RM) with partial blood-flow restriction training (BFRT), and a control group. Patients completed a 12-week supervised training program and were assessed for lower-extremity 1RM, quadriceps cross-sectional area (CSA), physical function (timed-stands test [TST], timed-up-and-go test [TUG], and Health Assessment Questionnaire [HAQ]), and quality of life (Short Form 36 health survey [SF-36]) at baseline and after the intervention. RESULTS: BFRT and HL-RT were similarly effective in increasing maximum dynamic strength in both leg press (22.8% and 24.2%, respectively; P < 0.0001 for all) and knee extension (19.7% and 23.8%, respectively; P < 0.0001 for all). Quadriceps CSA was also significantly increased in both BFRT and HL-RT (9.5% and 10.8%, respectively; P < 0.0001 for all). Comparable improvements in TST (11.2% and 14.7%; P < 0.0001 for all) and TUG (-6.8% [P < 0.0053] and -8.7% [P < 0.0001]) were also observed in BFRT and HL-RT, respectively. Improvements in both groups were significantly greater than those of the control group (P < 0.05 for all). SF-36 role physical and bodily pain and HAQ scores were improved only in BFRT (45.7%, 22.5%, and -55.9%, respectively; P < 0.05 for all). HL-RT resulted in 1 case of withdrawal and several cases of exercise-induced pain, which did not occur in BFRT. CONCLUSION: BFRT was effective in improving muscle strength, mass, function, and health-related quality of life in patients with RA, emerging as a viable therapeutic modality in RA management.
Subject(s)
Arthritis, Rheumatoid/rehabilitation , Regional Blood Flow , Resistance Training/methods , Aged , Female , Humans , Leg/blood supply , Middle Aged , Muscle Strength , Quadriceps Muscle/physiology , Quality of LifeABSTRACT
ABSTRACT Endovascular treatment for femoropopliteal arterial disease has made revascularization procedures less invasive, but the self-expanding stents used can suffer great wear in arteries with extreme mobility. Objective: to evaluate the prevalence of fractures in stents implanted in the femoropopliteal segment, to identify predisposing factors and consequences on arterial patency. Method: between March and June 2019, thirty patients previously operated for femoropopliteal obstruction underwent stent X-rays in anteroposterior and lateral views to detect fractures and Doppler to analyze arterial patency. Results: we observed 12 cases with fractures (33.3%): 1 type I (2.8%), 3 type II (8.3%), 5 type III (13.9%), 3 type IV (8.3%) and no type V. According to the TASC II we had 1 in group B (8.3%), 6 in group C (50%) and 5 in group D (41.6%) p <0.004. The number of stents per limb was 3.1 (± 1.3) in cases of fracture versus 2.3 (± 1.3) in cases without fracture (p = 0.08). The extension was 274.17mm (± 100.94) in cases of fracture and 230.83mm (± 135.44) in cases without fracture (p = 0.29). On Doppler we had: 17 patients (47.2%) without stenosis, 9 patients (25%) with stenosis> 50% and 10 patients (27.8%) with occlusion (p = 0.37). There was no correlation between fracture and arterial obstruction (p = 0.33). Conclusion: stent fractures are a frequent finding in the femoropopliteal area (33.3%), being more prevalent in cases of more advanced disease (C and D). There was no association between the finding of fracture and arterial obstruction.
RESUMO Os tratamentos endovasculares para a doença arterial obstrutiva fêmoro-poplítea tornaram os procedimentos de revascularização menos invasivos, porém os stents metálicos autoexpansíveis utilizados podem sofrer grande desgaste em artérias com extrema mobilidade. Objetivo: avaliar a prevalência de fraturas em stents implantados no segmento fêmoro-poplíteo, identificar fatores predisponentes e possíveis consequências sobre a patência arterial. Métodos: entre março a junho de 2019, trinta pacientes previamente operados por obstrução fêmoro-poplítea realizaram RX dos stents em incidências ântero-posterior e perfil para detectar fraturas e eco Doppler para analisar a patência arterial. Resultados: observamos 12 casos com fraturas (33,3%): 1 do tipo I (2,8%), 3 do tipo II (8,3%), 5 do tipo III (13,9%), 3 do tipo IV (8,3%) e nenhuma tipo V. Segundo a classificação TASC II, tivemos 1 no grupo B (8,3%), 6 no grupo C (50%) e 5 no grupo D (41,6%) p<0,004. O número de stents por membro foi de 3,1 (±1,3) nos casos de fratura contra 2,3 (±1,3) nos casos sem fratura (p = 0,08). A extensão tratada foi 274,17mm (±100,94) nos casos de fratura e 230,83mm (±135,44) nos casos sem fratura (p=0,29). No Doppler tivemos: 17 pacientes (47,2%) sem estenose, 9 pacientes (25%) com estenose>50% e 10 pacientes (27,8%) com oclusão (p=0,37). Não houve correlação entre fratura e obstrução arterial (p=0,33). Conclusão: as fraturas de stents são um achado frequente no setor fêmoro-poplíteo (33,3%) sendo mais prevalentes nos casos de doença mais avançada TASC II C e D. Não houve associação entre o achado de fratura e obstrução arterial.
Subject(s)
Humans , Popliteal Artery , Prosthesis Failure , Stents , Peripheral Vascular Diseases/therapy , Ultrasonography, Doppler, Color/methods , Peripheral Arterial Disease , Endovascular Procedures/methods , Prosthesis Design , Vascular Patency , Prevalence , Retrospective Studies , Risk Factors , Treatment Outcome , Peripheral Vascular Diseases/diagnostic imaging , Leg/blood supplyABSTRACT
BACKGROUND: Aneurysms of the deep veins of the lower limbs are rare and often asymptomatic. Although natural history is unclear, these aneurysms have been associated with deep venous thrombosis and fatal pulmonary embolism events. To our knowledge, this case represents the fifth patient with isolated aneurysm of a calf vein described in the literature and the second one affecting the fibular vein. METHODS: We report the case of a 20-year-old white man with an aneurysm of the fibular vein that we believe is the second case in the literature RESULTS: After evaluation and diagnosis, the aneurysm was resected with full recovery of the patient. CONCLUSIONS: Treatment of this unusual condition seems to be mandatory for major thromboembolic events can be as high as 71% with 2 deaths, according to a review of 24 patients with popliteal vein aneurysms. Unlike proximal veins, where reconstruction is advisable, calf vein aneurysms can be safely managed by simple excision and ligature. In our patient, aneurysm resection eliminated symptoms, and good result was maintained in long follow-up.
Subject(s)
Aneurysm , Leg/blood supply , Veins , Aneurysm/diagnostic imaging , Aneurysm/surgery , Humans , Ligation , Magnetic Resonance Angiography , Male , Phlebography , Ultrasonography, Doppler, Duplex , Vascular Surgical Procedures , Veins/diagnostic imaging , Veins/surgery , Young AdultABSTRACT
BACKGROUND: Peripheral arterial occlusive disease (PAOD) is a common cause of morbidity and mortality due to cardiovascular disease in the general population. Although numerous treatments have been adopted for patients at different disease stages, no option other than amputation is available for patients presenting with critical limb ischaemia (CLI) unsuitable for rescue or reconstructive intervention. In this regard, prostanoids have been proposed as a therapeutic alternative, with the aim of increasing blood supply to the limb with occluded arteries through their vasodilatory, antithrombotic, and anti-inflammatory effects. This is an update of a review first published in 2010. OBJECTIVES: To determine the effectiveness and safety of prostanoids in patients with CLI unsuitable for rescue or reconstructive intervention. SEARCH METHODS: For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (January 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). In addition, we searched trials registries (January 2017) and contacted pharmaceutical manufacturers, in our efforts to identify unpublished data and ongoing trials. SELECTION CRITERIA: Randomised controlled trials describing the efficacy and safety of prostanoids compared with placebo or other pharmacological control treatments for patients presenting with CLI without chance of rescue or reconstructive intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. We resolved disagreements by consensus or by consultation with a third review author. MAIN RESULTS: For this update, 15 additional studies fulfilled selection criteria. We included in this review 33 randomised controlled trials with 4477 participants; 21 compared different prostanoids versus placebo, seven compared prostanoids versus other agents, and five conducted head-to-head comparisons using two different prostanoids.We found low-quality evidence that suggests no clear difference in the incidence of cardiovascular mortality between patients receiving prostanoids and those given placebo (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.41 to 1.58). We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared with placebo (RR 0.97, 95% CI 0.86 to 1.09). Adverse events were more frequent with prostanoids than with placebo (RR 2.11, 95% CI 1.79 to 2.50; moderate-quality evidence). The most commonly reported adverse events were headache, nausea, vomiting, diarrhoea, flushing, and hypotension. We found moderate-quality evidence showing that prostanoids reduced rest-pain (RR 1.30, 95% CI 1.06 to 1.59) and promoted ulcer healing (RR 1.24, 95% CI 1.04 to 1.48) when compared with placebo, although these small beneficial effects were diluted when we performed a sensitivity analysis that excluded studies at high risk of bias. Additionally, we found evidence of low to very low quality suggesting the effects of prostanoids versus other active agents or versus other prostanoids because studies conducting these comparisons were few and we judged them to be at high risk of bias. None of the included studies assessed quality of life. AUTHORS' CONCLUSIONS: We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared against placebo. Moderate-quality evidence showed small beneficial effects of prostanoids for rest-pain relief and ulcer healing when compared with placebo. Additionally, moderate-quality evidence showed a greater incidence of adverse effects with the use of prostanoids, and low-quality evidence suggests that prostanoids have no effect on cardiovascular mortality when compared with placebo. None of the included studies reported quality of life measurements. The balance between benefits and harms associated with use of prostanoids in patients with critical limb ischaemia with no chance of reconstructive intervention is uncertain; therefore careful assessment of therapeutic alternatives should be considered. Main reasons for downgrading the quality of evidence were high risk of attrition bias and imprecision of effect estimates.
Subject(s)
Ischemia/drug therapy , Leg/blood supply , Peripheral Vascular Diseases/drug therapy , Prostaglandins/therapeutic use , Alprostadil/therapeutic use , Amputation, Surgical/statistics & numerical data , Epoprostenol/therapeutic use , Humans , Iloprost/therapeutic use , Ischemia/mortality , Leg/surgery , Leg Ulcer/drug therapy , Nafronyl/therapeutic use , Nicotinic Acids/therapeutic use , Pentoxifylline/therapeutic use , Prostaglandins/adverse effects , Randomized Controlled Trials as Topic , Vasodilator Agents/therapeutic useABSTRACT
BACKGROUND: Leukocytoclastic vasculitis is typically mediated by deposition of immune complexes and is related to many causes, including medication. To the best of our knowledge, leukocytoclastic vasculitis related to cisplatin has not yet been described in the scientific literature. CASE PRESENTATION: We report a rare case of leukocytoclastic vasculitis after the first cycle of high-dose cisplatin chemotherapy in a patient with larynx carcinoma. A 48-year-old Caucasian man with larynx carcinoma received a high-dose of cisplatin monochemotherapy (100 mg/m2 every 21 days), along with 70 Gy of radiotherapy divided into 35 sessions, as a therapeutic schedule. Twelve days after the first chemotherapy administration and after 8 sessions of radiotherapy (total of 16 Gy), the patient presented with acute onset of palpable purpura in the lower limbs. The patient was hospitalized for 10 days, and during this period, he underwent several examinations to rule out infectious, autoimmune, and neoplastic disorders. A skin biopsy showed leukocytoclastic vasculitis with a positive pattern for IgM and C3, as detected through direct immunofluorescence. Twenty-five days after cisplatin administration, the chemotherapy regimen was changed to carboplatin AUC 5, and the episodes of purpura ceased, reinforcing the hypothesis of an adverse reaction to cisplatin. CONCLUSIONS: Cisplatin can induce leukocytoclastic vasculitis and clinicians should be aware of this potential effect for better case management and diagnosis.
Subject(s)
Antineoplastic Agents/adverse effects , Cisplatin/adverse effects , Laryngeal Neoplasms/drug therapy , Vasculitis, Leukocytoclastic, Cutaneous/chemically induced , Antineoplastic Agents/therapeutic use , Cisplatin/therapeutic use , Humans , Laryngeal Neoplasms/complications , Laryngeal Neoplasms/radiotherapy , Leg/blood supply , Leg/pathology , Male , Middle Aged , Skin/blood supply , Skin/pathology , Vasculitis, Leukocytoclastic, Cutaneous/complications , Vasculitis, Leukocytoclastic, Cutaneous/pathologyABSTRACT
Heart failure is characterized by the inability of the cardiovascular system to maintain oxygen (O2) delivery (i.e., muscle blood flow in non-hypoxemic patients) to meet O2 demands. The resulting increase in fractional O2 extraction can be non-invasively tracked by deoxygenated hemoglobin concentration (deoxi-Hb) as measured by near-infrared spectroscopy (NIRS). We aimed to establish a simplified approach to extract deoxi-Hb-based indices of impaired muscle O2 delivery during rapidly-incrementing exercise in heart failure. We continuously probed the right vastus lateralis muscle with continuous-wave NIRS during a ramp-incremental cardiopulmonary exercise test in 10 patients (left ventricular ejection fraction <35%) and 10 age-matched healthy males. Deoxi-Hb is reported as % of total response (onset to peak exercise) in relation to work rate. Patients showed lower maximum exercise capacity and O2 uptake-work rate than controls (P<0.05). The deoxi-Hb response profile as a function of work rate was S-shaped in all subjects, i.e., it presented three distinct phases. Increased muscle deoxygenation in patients compared to controls was demonstrated by: i) a steeper mid-exercise deoxi-Hb-work rate slope (2.2±1.3 vs 1.0±0.3% peak/W, respectively; P<0.05), and ii) late-exercise increase in deoxi-Hb, which contrasted with stable or decreasing deoxi-Hb in all controls. Steeper deoxi-Hb-work rate slope was associated with lower peak work rate in patients (r=-0.73; P=0.01). This simplified approach to deoxi-Hb interpretation might prove useful in clinical settings to quantify impairments in O2 delivery by NIRS during ramp-incremental exercise in individual heart failure patients.
Subject(s)
Heart Failure/physiopathology , Hemoglobins/analysis , Leg/blood supply , Muscle, Skeletal/metabolism , Oxygen Consumption/physiology , Case-Control Studies , Exercise Test , Heart Failure/metabolism , Humans , Leg/physiopathology , Male , Middle Aged , Muscle, Skeletal/physiopathology , Prospective Studies , Spectroscopy, Near-InfraredABSTRACT
The aim of this retrospective study was to assess the hospitalizations of patients with or without diabetes mellitus (DM) who underwent nontraumatic lower extremity amputation (NLEA) with regard to demographic and hospitalization-related variables. It is a high proportion of hospital beds in developing countries, for patients with diabetes mellitus with lower extremity complications. Nontraumatic amputations of lower extremities rates is an important indicator to assess the effectiveness of efforts to reduce chronic complications related to diabetic foot.A total of 2,296 hospital admissions were analyzed with regard to gender, age, length of stay, type of financing, origin, diagnosis, number of hospital admissions and readmissions, and hospitalization outcome from 2001 to 2008 in a municipality of Southeast Brazil. The association between the independent variables and the number of hospitalizations of patients with or without diabetes was assessed using chi-square tests for gender, type of financing, and hospitalization outcome and using the Mann-Whitney U test for age and length of stay. A total of 58% were patients without diabetes, 62.6% were male, 74.5% were treated at a public health care service, and 7.6% died. The mean age was 62.7 years, the mean length of stay was of 9.5 days, and the mean number of readmissions was 2.29 times. The length of stay was higher (P < .001), and the number of men was lower (P = .001) among the patients with diabetes who were hospitalized compared with patients without diabetes.The number of hospitalizations related to NLEA increased among patients with diabetes but reduced among those without diabetes between 2001 and 2008.
Subject(s)
Amputation, Surgical/statistics & numerical data , Diabetes Mellitus/surgery , Hospitalization/trends , Leg/surgery , Amputation, Surgical/mortality , Brazil , Diabetes Mellitus/epidemiology , Female , Hospitalization/economics , Hospitalization/statistics & numerical data , Humans , Leg/blood supply , Length of Stay , Male , Middle Aged , Patient Outcome Assessment , Patient Readmission , Retrospective StudiesABSTRACT
OBJECTIVE: The contralateral limbs of patients with unilateral lymphedema in the lower limbs (LLs) can exhibit abnormal lymphatic circulation, even in the absence of lymphedema. This idea is based on a number of reports that have studied isolated cases using lymphoscintigraphy. It is likely that these patients previously had some form of lymphopathy, and the lymphedema arose after the action of some external factor. However, there are no studies in the literature that adequately assess the asymptomatic contralateral limbs of these patients or address the prevalence and characteristics of the abnormal lymphatic circulation in these limbs. The aim of this study was to assess the prevalence of abnormal lymphatic circulation in the asymptomatic contralateral limbs of patients with unilateral lymphedema of the LL. METHODS: Forty-three patients from the angiology and vascular surgery ward of the Hospital das Clínicas da Universidade Federal de Pernambuco with unilateral lymphedema of the LL underwent lymphoscintigraphy. All patients received a subcutaneous injection of 0.2 mL (74 MBq) of a solution of dextran 70 labeled with technetium Tc 99m in the first interdigital space of each foot. Images were obtained on two occasions: 10 minutes and 1 hour after the injection. The study design was transversal prospective. RESULTS: Among the 43 asymptomatic LLs, 30 (70%) showed abnormal lymphatic circulation. The lymphoscintigraphic abnormalities found were the following: reduced visualization of the lymphatic vessels and lymph nodes during 1 hour (83%), collateral circulation (30%), visualization of the inguinal and pelvic lymph nodes after at least 1 hour (30%), visualization of the popliteal lymph nodes (20%), dilation and lymphatic tortuosity (20%), and dermal backflow (10%). CONCLUSIONS: In this study,70% of the patients with unilateral lymphedema of the LL had some form of lymphopathy in the contralateral limb during the lymphoscintigraphic examination. These findings could favor the early treatment of these patients to prevent the disease from progressing to its most severe stage.