Tapered reinforced graft and vein cuff in the distal anastomosis as adjunct strategies for infrapopliteal prosthetic bypass graft in chronic limb-threatening ischemia: A case report.

The great saphenous vein is the optimal conduit for infrapopliteal bypass surgery in chronic limb-threatening ischemia. A prosthetic bypass graft is an acceptable option when the autologous vein is unavailable and the anatomy is not favorable for endovascular therapy. However, the low patency rate of prosthetic grafts calls for adjunct strategies to improve the outcomes. Tapered reinforced grafts and vein cuffs are proposed measures. We herein present a case of a 78-year-old man with chronic limb-threatening ischemia and an extensive necrotic lesion on the dorsum of the left foot. He was successfully treated with a prosthetic bypass using two adjunct strategies to help improve patency: a tapered reinforced graft and a vein cuff in the distal anastomosis. After debridement and partial skin grafting, the wound healed completely in 2 months. The bypass graft was patent for 1 year.

Rivaroxaban versus no anticoagulation for post-discharge thromboprophylaxis after hospitalisation for COVID-19 (MICHELLE): an open-label, multicentre, randomised, controlled trial.

BACKGROUND: Patients hospitalised with COVID-19 are at risk for thrombotic events after discharge; the role of extended thromboprophylaxis in this population is unknown. METHODS: In this open-label, multicentre, randomised trial conducted at 14 centres in Brazil, patients hospitalised with COVID-19 at increased risk for venous thromboembolism (International Medical Prevention Registry on Venous Thromboembolism [IMPROVE] venous thromboembolism [VTE] score of ≥4 or 2-3 with a D-dimer >500 ng/mL) were randomly assigned (1:1) to receive, at hospital discharge, rivaroxaban 10 mg/day or no anticoagulation for 35 days. The primary efficacy outcome in an intention-to-treat analysis was a composite of symptomatic or fatal venous thromboembolism, asymptomatic venous thromboembolism on bilateral lower-limb venous ultrasound and CT pulmonary angiogram, symptomatic arterial thromboembolism, and cardiovascular death at day 35. Adjudication was blinded. The primary safety outcome was major bleeding. The primary and safety analyses were carried out in the intention-to-treat population. This trial is registered at ClinicalTrials.gov, NCT04662684. FINDINGS: From Oct 8, 2020, to June 29, 2021, 997 patients were screened. Of these patients, 677 did not meet eligibility criteria; the remaining 320 patients were enrolled and randomly assigned to receive rivaroxaban (n=160 [50%]) or no anticoagulation (n=160 [50%]). All patients received thromboprophylaxis with standard doses of heparin during hospitalisation. 165 (52%) patients were in the intensive care unit while hospitalised. 197 (62%) patients had an IMPROVE score of 2-3 and elevated D-dimer levels and 121 (38%) had a score of 4 or more. Two patients (one in each group) were lost to follow-up due to withdrawal of consent and not included in the intention-to-treat primary analysis. The primary efficacy outcome occurred in five (3%) of 159 patients assigned to rivaroxaban and 15 (9%) of 159 patients assigned to no anticoagulation (relative risk 0·33, 95% CI 0·12-0·90; p=0·0293). No major bleeding occurred in either study group. Allergic reactions occurred in two (1%) patients in the rivaroxaban group. INTERPRETATION: In patients at high risk discharged after hospitalisation due to COVID-19, thromboprophylaxis with rivaroxaban 10 mg/day for 35 days improved clinical outcomes compared with no extended thromboprophylaxis. FUNDING: Bayer.

Endovascular repair of a ruptured abdominal aortic aneurysm after endovascular aneurysm repair due type IB endoleak associated with a late fistula between the abdominal aorta and a retroaortic left renal vein.

A ruptured abdominal aortic aneurysm after endovascular aneurysm repair with an arteriovenous fistula between the aneurysm sac and a retroaortic left renal vein is an extremely rare complication. This case describes an 81-year-old man who developed an aorto-left renal vein fistula owing to a type IB endoleak 2 years after endovascular aneurysm exclusion. The leak was repaired with a left endograft limb extension. Endovascular techniques are attractive and feasible alternatives and can play an essential role in reinterventions. This report is the first of an aorto-left renal vein fistula owing a type IB endoleak after an endovascular aneurysm repair.

Evaluation of postoperative complications in elderly patients submitted to parotidectomy. / Avaliação das complicações pós-operatórias em pacientes idosos submetidos à parotidectomia.

OBJECTIVE: to evaluate the most incident histological subtypes and the main postoperative complications in elderly patients with parotid tumors submitted to parotidectomy. METHODS: we conducted a retrospective study with 57 elderly patients submitted to parotidectomy from 2003 to 2017, at the São José County Hospital of Joinville, Santa Catarina, Brazil. RESULTS: thirty-three (57.9%) patients had benign tumors, the most frequent being Warthin's tumor, and 17 (29.8%), malignant tumors, squamous cell carcinoma being the most frequent. Seven patients (12.3%) presented clinical complications, arterial pressure instability and respiratory complications being the most frequent, in four (7%) and three (5.3%) cases, respectively. Thirteen (22.1%) patients presented complications related to the surgical wound, hematoma and wound infection being the most frequent, with six (10.5%) cases each. Twenty-four (42.1%) patients had some degree of facial nerve dysfunction in the postoperative period, Brackman-House grade III being the most frequent, in 11 cases (19.3%). Surgical time and lymphadenectomy were associated with clinical complications. The main variables that showed an association with surgical complications were tumor size, longer surgical time, reoperation, and perioperative crystalloid infusion volume. CONCLUSION: parotid neoplasms present a differentiated profile in the elderly population, especially Warthin's tumor and squamous cell carcinoma. Hematoma and infection of the operative wound and facial nerve lesions were the most prevalent complications in the postoperative period.

OBJETIVO: avaliar subtipos histológicos mais incidentes e as principais complicações pós-operatórias em pacientes idosos portadores de tumor de parótida e submetidos à parotidectomia. MÉTODOS: estudo retrospectivo de 57 pacientes idosos submetidos à parotidectomia, no período de 2003 a 2017, no Hospital Municipal São José de Joinville, Santa Catarina, Brasil. RESULTADOS: trinta e três (57,9%) pacientes tinham tumores benignos, sendo o mais frequente o tumor de Warthin, e 17(29,8%) tumores malignos, sendo o carcinoma escamoso o mais frequente. Sete (12,3%) pacientes evoluíram com complicações clínicas, sendo a labilidade pressórica e as complicações respiratórias as mais incidentes em quatro (7%) e três (5,3%) casos, respectivamente. Treze (22,1%) pacientes apresentaram complicações cirúrgicas relacionadas à ferida operatória, sendo o hematoma e a infecção de ferida as mais incidentes, com seis (10,5%) casos cada. Vinte e quatro (42,1%) pacientes tiveram algum grau de disfunção do nervo facial no pós-operatório, sendo o grau III de Brackman-House, em 11 casos (19,3%), o mais frequente. O tempo cirúrgico e a linfadenectomia mostraram associação com complicações clínicas. As principais variáveis que apresentaram associação com complicações cirúrgicas foram: tamanho do tumor, tempo cirúrgico mais longo, reoperação e volume de infusão de cristaloides no transoperatório. CONCLUSÃO: as neoplasias parotídeas apresentam perfil diferenciado na população idosa, destacando-se o tumor de Warthin e o carcinoma escamoso. Hematoma e infecção da ferida operatória, e as lesões do nervo facial foram as complicações mais prevalentes no pós-operatório.

Avaliação das complicações pós-operatórias em pacientes idosos submetidos à parotidectomia / Evaluation of postoperative complications in elderly patients submitted to parotidectomy

RESUMO Objetivo: avaliar subtipos histológicos mais incidentes e as principais complicações pós-operatórias em pacientes idosos portadores de tumor de parótida e submetidos à parotidectomia. Métodos: estudo retrospectivo de 57 pacientes idosos submetidos à parotidectomia, no período de 2003 a 2017, no Hospital Municipal São José de Joinville, Santa Catarina, Brasil. Resultados: trinta e três (57,9%) pacientes tinham tumores benignos, sendo o mais frequente o tumor de Warthin, e 17(29,8%) tumores malignos, sendo o carcinoma escamoso o mais frequente. Sete (12,3%) pacientes evoluíram com complicações clínicas, sendo a labilidade pressórica e as complicações respiratórias as mais incidentes em quatro (7%) e três (5,3%) casos, respectivamente. Treze (22,1%) pacientes apresentaram complicações cirúrgicas relacionadas à ferida operatória, sendo o hematoma e a infecção de ferida as mais incidentes, com seis (10,5%) casos cada. Vinte e quatro (42,1%) pacientes tiveram algum grau de disfunção do nervo facial no pós-operatório, sendo o grau III de Brackman-House, em 11 casos (19,3%), o mais frequente. O tempo cirúrgico e a linfadenectomia mostraram associação com complicações clínicas. As principais variáveis que apresentaram associação com complicações cirúrgicas foram: tamanho do tumor, tempo cirúrgico mais longo, reoperação e volume de infusão de cristaloides no transoperatório. Conclusão: as neoplasias parotídeas apresentam perfil diferenciado na população idosa, destacando-se o tumor de Warthin e o carcinoma escamoso. Hematoma e infecção da ferida operatória, e as lesões do nervo facial foram as complicações mais prevalentes no pós-operatório.

ABSTRACT Objective: to evaluate the most incident histological subtypes and the main postoperative complications in elderly patients with parotid tumors submitted to parotidectomy. Methods: we conducted a retrospective study with 57 elderly patients submitted to parotidectomy from 2003 to 2017, at the São José County Hospital of Joinville, Santa Catarina, Brazil. Results: thirty-three (57.9%) patients had benign tumors, the most frequent being Warthin's tumor, and 17 (29.8%), malignant tumors, squamous cell carcinoma being the most frequent. Seven patients (12.3%) presented clinical complications, arterial pressure instability and respiratory complications being the most frequent, in four (7%) and three (5.3%) cases, respectively. Thirteen (22.1%) patients presented complications related to the surgical wound, hematoma and wound infection being the most frequent, with six (10.5%) cases each. Twenty-four (42.1%) patients had some degree of facial nerve dysfunction in the postoperative period, Brackman-House grade III being the most frequent, in 11 cases (19.3%). Surgical time and lymphadenectomy were associated with clinical complications. The main variables that showed an association with surgical complications were tumor size, longer surgical time, reoperation, and perioperative crystalloid infusion volume. Conclusion: parotid neoplasms present a differentiated profile in the elderly population, especially Warthin's tumor and squamous cell carcinoma. Hematoma and infection of the operative wound and facial nerve lesions were the most prevalent complications in the postoperative period.

Achado Radiológico de Cisto Pericárdico / Radiologic Finding of Pericardial Cyst

Mulher de 46 anos de idade, em acompanhamento porinfecção cutânea por Bukhoderia pseudomallei em membrosuperior esquerdo, realizou radiografia de tórax para descartaracometimento pulmonar, que evidenciou hipotransparênciaem lobo inferior esquerdo (Figura 1A). Posteriormente, foisubmetida a tomografia de tórax que demonstrou coleçãolíquida, sem realce pelo meio de contraste, medindo 8cm no maior eixo axial, ocupando o seio cardiofrênicoesquerdo (Figura 1B). O ecocardiograma transtorácico (ECO)mostrou função sistólica preservada (FE 62% pelo Teichholz),espessamento pericárdico discreto e cisto pericárdico emregião posterior e em ponta do coração, contendo traves defibrina (Figura 2). Posteriormente, a paciente foi submetidaa drenagem percutânea do cisto guiada por US (citologia:hemácias 0, leucócitos 1.000, 60% mononucleares e 40%neutrófilos; cultura negativa). O ECO realizado um mês apósa drenagem demonstrou discreto espessamento pericárdico(4 mm) e ausência de derrame pericárdico. Paciente segueem tratamento ambulatorial com o infectologista.Cistos pericárdicos são anomalias congênitas raras egeralmente benignas. Representam 6% das massas mediastinaise 33% de todos os cistos do mediastino. A grande maioriados cistos é assintomática e geralmente é achado incidentalem exames de imagens que podem ser confundidos comaneurisma da artéria coronariana, neoplasias e pneumonia.Complicações como a ruptura do cisto, compressão cardíacae até mesmo morte súbita já forma descritas, porém sãoincomuns. Pode-se adotar uma conduta conservadora emcasos assintomáticos desde que seja possível o seguimentodo paciente, de forma a garantir um curso benigno em que ocisto pericárdico pode involuir espontaneamente...

Monitoria em técnica cirúrgica e anestesiologia: utilidade do curso de preparatório voltado para acadêmicos de medicina / Monitoring in anesthesiology and surgical technique: preparatory course utility facing medical students

No presente artigo os autores discutem a importância do curso preparatório para monitores da disciplina de Técnica Cirúrgica e Anestesiologia (TCA). Os resultados foram obtidos por meio de questionário objetivo que expressa opiniões sobre o curso, manifestadas pelos monitores, o que proporciona uma análise da importância das atividades ofertadas no curso de capacitação. O objetivo principal almejado pelos participantes era conseguir mais experiência nas áreas abordadas. O curso de capacitação colaborou para a aquisição de mais segurança aos alunos que irão exercer o papel de instrutores nas aulas práticas da disciplina. Nas demais questões abordadas, o curso foi de grande aceitação pelos participantes, pois a maioria afirma que o curso ajudou a alcançar os objetivos primários, teve carga horária suficiente, e tornou os alunos aptos para auxiliar nas aulas práticas da disciplina de TCA. Verificou-se a homogeneidade do entendimento dos assuntos abordados por meio de um exame composto por 4 questões referentes a situações práticas abordados no curso. Nos resultados obtidos, ficou clara a importância do curso de capacitação na complementação do conhecimento e no preparo do monitor, pois sintetiza os principais tópicos da disciplina de Técnica Cirúrgica e Anestesiologia de forma a facilitar a aplicabilidade prática. Portanto, o curso de capacitação permite a transmissão de informações homogêneas aos acadêmicos que cursam a disciplina, desenvolve e fixa o conhecimento dos monitores, além de dar suporte às aulas práticas. Dessa forma, a transmissão de conhecimentos e experiências ocorre de forma recíproca entre os acadêmicos, favorecendo o desenvolvimento pessoal e profissional.

In this paper the authors discuss the importance of the preparatory course for instructors of Surgical Technique discipline and Anesthesiology (TCA). The results were obtained through a questionnaire goal expressing opinions on the course, manifested by the monitors, which provides an analysis of the importance of the activities offered in the training course. The main objective pursued by the participants was to get more experience in this area. The training course helped students to acquire more security to play the role of trainers in the practical lessons of discipline. In the other issues addressed, the course was well accepted by the participants, since most states that the course helped achieve the primary goals, had enough hours, and students become able to assist in the practical lessons of discipline. There was homogeneity of understanding of the issues addressed, confirmed by an exam consisted of 4 questions regarding practical situations covered in the course. With the results obtained, it became clear the importance of the training course to complement the knowledge and prepare the futures monitors, because it summarizes the main topics of the discipline Surgical Technique and Anesthesiology in order to facilitate the practical applicability. Therefore, the training course allows the transmission of homogenous information to academics who study the discipline, develops and secures the knowledge of the monitors, and support the practical classes. Thus, the transmission of knowledge and experience takes place on a reciprocal basis between the academic, favoring personal and professional development.

Incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting / Incidência de fibrilação atrial no pós-operatório de pacientes submetidos à cirurgia de revascularização do miocárdio com e sem circulação extracorpórea

AbstractObjective:To determine the incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting.Methods:A retrospective study with analysis of 230 medical records between January 2011 and October 2013 was conducted.Results:Fifty-six (24.3%) out of the 230 patients were female. The average age of patients undergoing on-pump coronary artery bypass grafting was 59.91±8.62 years old, and off-pump was 57.16±9.01 years old (P=0.0213). The average EuroSCORE for the on-pump group was 3.37%±3.08% and for the off-pump group was 3.13%±3% (P=0.5468). Eighteen (13.43%) patients who underwent off-pump coronary artery bypass grafting developed postoperative atrial fibrillation, whereas for the onpump group, 19 (19.79%) developed this arrhythmia, with no significant difference between the groups (P=0.1955).Conclusion:Off-pump coronary artery bypass grafting did not reduce the incidence of atrial fibrillation in the postoperative period. Important predictors of risk for the development of this arrhythmia were identified as: patients older than 70 years old and presence of atrial fibrillation in perioperative period in both groups, and non-use of beta-blockers drugs postoperatively in the on-pump group.

ResumoObjetivo:Determinar a incidência de fibrilação atrial no pós -operatório de pacientes submetidos à cirurgia de revascularização do miocárdio com e sem circulação extracorpórea.Métodos:Foi realizado um estudo retrospectivo com análise de 230 prontuários entre janeiro de 2011 e outubro de 2013.Resultados:Do total de 230 pacientes, 56 (24,3%) eram do sexo feminino. A média de idade dos pacientes submetidos à cirurgia de revascularização do miocárdio com circulação extracorpórea foi de 59,91±8,62 anos, e sem circulação extracorpórea, foi de 57,16±9,01 anos (P=0,0213). A média do Euroscore para o grupo com circulação extracorpórea foi de 3,37%±3,08% e para o grupo sem circulação extracorpórea foi de 3,13%±3% (P=0,5468). Entre os pacientes que realizaram a cirurgia de revascularização do miocárdio sem circulação extracorpórea, 18 (13,43%) desenvolveram fibrilação atrial no pós-operatório, enquanto no grupo com circulação extracorpórea, 19 (19,79%) desenvolveram esta arritmia, não havendo diferença significativa entre os grupos (P=0,1955).Conclusão:A cirurgia de revascularização do miocárdio sem circulação extracorpórea não diminuiu a incidência de fibrilação atrial no período pós-operatório. Identificamos como preditores de risco para o desenvolvimento desta arritmia: idade superior a 70 anos e presença de fibrilação atrial no período transoperatório em ambos os grupos estudados, e o não uso de medicamentos betabloqueadores no pós-operatório do grupo com circulação extracorpórea.

Tratamento do aneurisma aterosclerótico da artéria temporal superficial: relato de caso / Treatment of an atherosclerotic aneurysm of the superficial temporal artery: case report

Aneurismas da artéria temporal superficial são incomuns segundo a literatura. A grande maioria é secundária a traumatismos ou cirurgia na região temporal, sendo que 95% dos casos evoluem para pseudoaneurismas. Entretanto, os aneurismas verdadeiros ou espontâneos são extremamente raros e representam 8% dos casos de aneurismas da artéria temporal superficial, sendo estes, geralmente, de origem aterosclerótica. Aneurismas temporais espontâneos podem coexistir com outras lesões vasculares, incluindo aneurismas intracranianos. Nosso relato trata de um paciente com aneurisma de artéria temporal superficial esquerda, de origem aterosclerótica, no qual foi realizada a excisão cirúrgica, sob anestesia geral.

According to the literature, aneurysms of the superficial temporal artery are uncommon. The vast majority are secondary to trauma or surgery in the temporal region and 95% of cases progress to pseudoaneurysms. However, true or spontaneous aneurysms are extremely rare, accounting for 8% of cases of superficial temporal artery aneurysms, and are usually caused by atherosclerosis. Spontaneous temporal aneurysms can coexist with other vascular lesions, including intracranial aneurysms. Our report deals with a patient with an aneurysm of the left superficial temporal artery, of atherosclerotic origin, for whom surgical excision was performed under general anesthesia.

Incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting.

OBJECTIVE: To determine the incidence of postoperative atrial fibrillation in patients undergoing on-pump and off-pump coronary artery bypass grafting. METHODS: A retrospective study with analysis of 230 medical records between January 2011 and October 2013 was conducted. RESULTS: Fifty-six (24.3%) out of the 230 patients were female. The average age of patients undergoing on-pump coronary artery bypass grafting was 59.91±8.62 years old, and off-pump was 57.16±9.01 years old (P=0.0213). The average EuroSCORE for the on-pump group was 3.37%±3.08% and for the off-pump group was 3.13%±3% (P=0.5468). Eighteen (13.43%) patients who underwent off-pump coronary artery bypass grafting developed postoperative atrial fibrillation, whereas for the onpump group, 19 (19.79%) developed this arrhythmia, with no significant difference between the groups (P=0.1955). CONCLUSION: Off-pump coronary artery bypass grafting did not reduce the incidence of atrial fibrillation in the postoperative period. Important predictors of risk for the development of this arrhythmia were identified as: patients older than 70 years old and presence of atrial fibrillation in perioperative period in both groups, and non-use of beta-blockers drugs postoperatively in the on-pump group.