Stenting or angioplasty for the treatment of deep vein thrombosis: Systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Although the cornerstone treatment for deep vein thrombosis (DVT) remains anticoagulation, clinicians perform stenting or angioplasty (SA) in particular patients. To assess the effects of SA in this setting, we performed a systematic review of randomized controlled trials. METHODS: Based on the Cochrane standards, we searched the Cochrane CENTRAL, MEDLINE, Embase, CINAHL, LILACS and IBECS databases, and trial registries. Our primary outcomes were post-thrombotic syndrome (PTS), venous thromboembolism (VTE) and all-cause mortality. RESULTS: We included 7 randomized controlled trial (1485 participants). There was no clinically significant difference between SA and best medical practice (BMP) for the additional treatment of acute DVT regarding PTS (standardized mean difference -7.87, 95% confidence interval [CI] -12.13 to -3.61; very low-certainty) and VTE (risk ratio [RR] 1.19, 95% CI 0.28-5.07, very low-certainty), and no deaths. Compared to BMP, the SA plus BMP and thrombolysis results in little to no difference in PTS (mean difference [MD] -1.07, 95% CI -1.12 to -1.02, moderate-certainty), VTE (RR 1.48, 95% CI 0.95-2.31, low-certainty), and mortality (RR 0.92, 95% CI 0.34-2.52, low-certainty). There was no clinical difference between stenting and BMP for chronic DVT regarding PTS (MD 2.73, 95% CI -2.10 to 7.56, very low certainty) and no VTE and death events. CONCLUSIONS: SA results in little to no difference in PTS, VTE and mortality in acute DVT compared to BMP. The evidence regarding SA in chronic DVT and whether SA, compared to BMP and thrombolysis, decreases PTS and VTE in acute DVT is uncertain. Open Science Framework (osf.io/f2dm6).

What do Cochrane systematic reviews say about congenital vascular anomalies and hemangiomas? A narrative review.

BACKGROUND: Congenital vascular anomalies and hemangiomas (CVAH) such as infantile hemangiomas, port-wine stains and brain arteriovenous malformations (AVMs) impair patients' lives and may require treatment if complications occur. However, a great variety of treatments for those conditions exist and the best interventions remain under discussion. OBJECTIVE: To summarize Cochrane systematic review (SR) evidence on treatments for CVAH. DESIGN AND SETTING: Review of SRs conducted in the Division of Vascular and Endovascular Surgery of Universidade Federal de São Paulo, Brazil. METHODS: A broad search was conducted on March 9, 2021, in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed treatments for CVAH. The key characteristics and results of all SRs included were summarized and discussed. RESULTS: A total of three SRs fulfilled the inclusion criteria and were presented as a qualitative synthesis. One SR reported a significant clinical reduction of skin redness by at least 20%, with more pain, among 103 participants with port-wine stains. One SR reported that propranolol improved the likelihood of clearance 13 to 16-fold among 312 children with hemangiomas. One SR reported that the relative risk of death or dependence was 2.53 times greater in the intervention arm than with conservative management, among 218 participants with brain AVMs. CONCLUSION: Cochrane reviews suggest that treatment of port-wine stains with pulsed-dye laser improves redness; propranolol remains the best option for infantile hemangiomas; and conservative management seems to be superior to surgical intervention for treating brain AVMs.

What do Cochrane systematic reviews say about congenital vascular anomalies and hemangiomas? A narrative review

ABSTRACT BACKGROUND: Congenital vascular anomalies and hemangiomas (CVAH) such as infantile hemangiomas, port-wine stains and brain arteriovenous malformations (AVMs) impair patients' lives and may require treatment if complications occur. However, a great variety of treatments for those conditions exist and the best interventions remain under discussion. OBJECTIVE: To summarize Cochrane systematic review (SR) evidence on treatments for CVAH. DESIGN AND SETTING: Review of SRs conducted in the Division of Vascular and Endovascular Surgery of Universidade Federal de São Paulo, Brazil. METHODS: A broad search was conducted on March 9, 2021, in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed treatments for CVAH. The key characteristics and results of all SRs included were summarized and discussed. RESULTS: A total of three SRs fulfilled the inclusion criteria and were presented as a qualitative synthesis. One SR reported a significant clinical reduction of skin redness by at least 20%, with more pain, among 103 participants with port-wine stains. One SR reported that propranolol improved the likelihood of clearance 13 to 16-fold among 312 children with hemangiomas. One SR reported that the relative risk of death or dependence was 2.53 times greater in the intervention arm than with conservative management, among 218 participants with brain AVMs. CONCLUSION: Cochrane reviews suggest that treatment of port-wine stains with pulsed-dye laser improves redness; propranolol remains the best option for infantile hemangiomas; and conservative management seems to be superior to surgical intervention for treating brain AVMs.

Effectiveness and safety of structured exercise vs. no exercise for asymptomatic aortic aneurysm: systematic review and meta-analysis.

We conducted a systematic review to compare the effectiveness and safety of exercise versus no exercise for patients with asymptomatic aortic aneurysm. We followed the guidelines set out in the Cochrane systematic review handbook. We searched Medline, Embase, CENTRAL, LILACS, PeDRO, CINAHL, clinicaltrials.gov, ICTRP, and OpenGrey using the MeSH terms "aortic aneurysm" and "exercise". 1189 references were identified. Five clinical trials were included. No exercise-related deaths or aortic ruptures occurred in these trials. Exercise did not reduce the aneurysm expansion rate at 12 weeks to 12 months (mean difference [MD], -0.05; 95% confidence interval [CI], -0.13 to 0.03). Six weeks of preoperative exercise reduced severe renal and cardiac complications (risk ratio, 0.54; 95% CI, 0.31-0.93) and the length of intensive care unit stay (MD, -1.00; 95% CI, -1.26 to -0.74). Preoperative and postoperative forward walking reduced the length of hospital stay (MD, -0.69; 95% CI, -1.24 to -0.14). The evidence was graded as 'very low' level.

Foi realizada revisão sistemática para comparar a efetividade e a segurança de exercícios versus não exercícios em pacientes assintomáticos com aneurisma de aorta. Usamos os termos MeSH aortic aneurysm e exercise para as bases MEDLINE, Embase, CENTRAL, LILACS, PeDRO, CINAHL, clinicaltrials.gov, International Clinical Trials Registry Platform (ICTRP) e OpenGrey. Foram obtidas 1.189 referências. Cinco ensaios clínicos foram incluídos. Não houve morte ou rotura associada ao exercício. Além disso, este não reduziu a velocidade de crescimento do aneurisma em 12 semanas a 12 meses [diferença de médias (DM) −0,05; intervalo de confiança de 95% (IC95%) −0,13 a 0,03]. Seis semanas de exercícios pré-operatórios reduziram complicações clínicas renais e cardíacas (razão de risco 0,54; IC95% 0,31­0,93) e a permanência em unidade de terapia intensiva (DM −1,00; IC95% −1,26 a −0,74). Caminhadas nos períodos pré e pós-operatório reduziram a permanência hospitalar. A evidência foi classificada como de muito baixa qualidade.

Effectiveness and safety of structured exercise vs. no exercise for asymptomatic aortic aneurysm: systematic review and meta-analysis / Efetividade e segurança de exercícios estruturados versus sem exercício em pacientes assintomáticos com aneurisma de aorta: revisão sistemática e metanálise

Abstract We conducted a systematic review to compare the effectiveness and safety of exercise versus no exercise for patients with asymptomatic aortic aneurysm. We followed the guidelines set out in the Cochrane systematic review handbook. We searched Medline, Embase, CENTRAL, LILACS, PeDRO, CINAHL, clinicaltrials.gov, ICTRP, and OpenGrey using the MeSH terms "aortic aneurysm" and "exercise". 1189 references were identified. Five clinical trials were included. No exercise-related deaths or aortic ruptures occurred in these trials. Exercise did not reduce the aneurysm expansion rate at 12 weeks to 12 months (mean difference [MD], −0.05; 95% confidence interval [CI], −0.13 to 0.03). Six weeks of preoperative exercise reduced severe renal and cardiac complications (risk ratio, 0.54; 95% CI, 0.31-0.93) and the length of intensive care unit stay (MD, −1.00; 95% CI, −1.26 to −0.74). Preoperative and postoperative forward walking reduced the length of hospital stay (MD, −0.69; 95% CI, −1.24 to −0.14). The evidence was graded as 'very low' level.

Resumo Foi realizada revisão sistemática para comparar a efetividade e a segurança de exercícios versus não exercícios em pacientes assintomáticos com aneurisma de aorta. Usamos os termos MeSH aortic aneurysm e exercise para as bases MEDLINE, Embase, CENTRAL, LILACS, PeDRO, CINAHL, clinicaltrials.gov, International Clinical Trials Registry Platform (ICTRP) e OpenGrey. Foram obtidas 1.189 referências. Cinco ensaios clínicos foram incluídos. Não houve morte ou rotura associada ao exercício. Além disso, este não reduziu a velocidade de crescimento do aneurisma em 12 semanas a 12 meses [diferença de médias (DM) −0,05; intervalo de confiança de 95% (IC95%) −0,13 a 0,03]. Seis semanas de exercícios pré-operatórios reduziram complicações clínicas renais e cardíacas (razão de risco 0,54; IC95% 0,31-0,93) e a permanência em unidade de terapia intensiva (DM −1,00; IC95% −1,26 a −0,74). Caminhadas nos períodos pré e pós-operatório reduziram a permanência hospitalar. A evidência foi classificada como de muito baixa qualidade.

What do Cochrane systematic reviews say about ultrasound-guided vascular access?

BACKGROUND: Ultrasonography is currently used in investigating many vascular diseases, especially for guiding vascular access. OBJECTIVE: The objective here was to summarize the evidence from Cochrane systematic reviews (SRs) on the effects of ultrasound-guided vascular access as an intervention approach. DESIGN AND SETTING: Review of SRs, conducted in the Division of Vascular and Endovascular Surgery of Universidade Federal de São Paulo. METHODS: A broad search was conducted in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed the effects of ultrasound guidance as a therapeutic approach towards performing any vascular access. The key characteristics and results of all the reviews included were summarized and discussed. RESULTS: Three SRs on venous access at all ages and one review on arterial access in pediatric participants were included. There was low to moderate certainty of evidence that ultrasound increased the success rate from the first puncture and the overall success rate of the procedure; and reduced the total rate of perioperative and postoperative adverse events, number of punctures, time needed to achieve success and rate of failure to place catheters. CONCLUSION: Evidence of low to moderate quality showed that ultrasound-guided vascular access seems to reduce the total rate of perioperative and postoperative complications/adverse effects, number of punctures, time needed to achieve success and rate of failure to perform venous catheterization in adults and arterial punctures in children. There is a lack of information regarding ultrasound-guided arterial puncture in adults. Further studies are still imperative for reaching solid conclusions, especially regarding arterial ultrasound-guided access.

Angioplasty and stenting for below the knee ulcers in diabetic patients: protocol for a systematic review.

BACKGROUND: The worldwide incidence and prevalence of diabetes mellitus (DM) are increasing. DM has a high social and economic burden due to its complications and associated disorders. Peripheral arterial disease (PAD) is closely related to DM. More than 85% of patients with DM will develop PAD in their lifetime, and between 10 and 25% of patients with DM will have a foot ulcer. In such cases, it is important to determine for each patient whether it is necessary and feasible to revascularise the affected limb as well as the optimal technique. Percutaneous transluminal angioplasty (PTA) is designed to restore blood flow through the vessel lumen by various devices including balloons, drug-coated balloons, bare stents, drug-eluting stents and endovascular atherectomes. This systematic review aims to evaluate the effects of PTA in the treatment of lower limb arterial ulcers in diabetic patients. METHODS: We will search randomised controlled trials (RCTs) and quasi-RCTs in the following databases (e.g., MEDLINE via PubMed, EMBASE, Lilacs, Cochrane Central Register of Controlled Trials, Ibecs, CINAHL, AMED, World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov , and OpenGrey). Our search strategy will use the following free-text terms and controlled vocabulary (e.g., Emtree, MeSH) for 'foot ulcer', 'leg ulcer', 'diabetic foot', 'Peripheral Arterial Disease', 'Diabetes Complications', 'Peripheral Vascular Diseases', 'critical limb ischemia', 'below the knee ulcer', 'angioplasty', 'stents', 'stenting', and 'endovascular procedures'. There will be no limits on date or language of publication. Two authors will, independently, select studies and assess the data from them. Risks of bias (RoB) of included studies will be evaluated using the Cochrane's RoB tool. If possible, we will perform and report structured summaries of the included studies and meta-analyses. Results are not available as this is a protocol for a systematic review, and we are currently in the phase of building a sensitive search strategy. DISCUSSION: While there are several available endovascular techniques for revascularisation, it is unclear which technique has better outcomes for ulcers below the knee in diabetic patients. A systematic review is required to validate and demonstrate these techniques and their outcomes to allow an evidence-based clinical decision. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017065171.

Immediate versus delayed treatment for recently symptomatic carotid artery stenosis

ABSTRACT BACKGROUND: The timing of surgery for recently symptomatic carotid artery stenosis remains controversial. Early cerebral revascularization may prevent a disabling or fatal ischemic recurrence, but it may also increase the risk of hemorrhagic transformation, or of dislodging a thrombus. This review examined the randomized controlled evidence that addressed whether the increased risk of recurrent events outweighed the increased benefit of an earlier intervention. OBJECTIVES: To assess the risks and benefits of performing very early cerebral revascularization (within two days) compared with delayed treatment (after two days) for people with recently symptomatic carotid artery stenosis. METHODS: Search methods: We searched the Cochrane Stroke Group Trials Register in January 2016, the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2016, issue 1), MEDLINE (1948 to 26 January 2016), EMBASE (1974 to 26 January 2016), LILACS (1982 to 26 January 2016), and trial registers (from inception to 26 January 2016). We also handsearched conference proceedings and journals, and searched reference lists. There were no language restrictions. We contacted colleagues and pharmaceutical companies to identify further studies and unpublished trials Selection criteria: All completed, truly randomized trials (RCT) that compared very early cerebral revascularization (within two days) with delayed treatment (after two days) for people with recently symptomatic carotid artery stenosis. Data collection and analysis: We independently selected trials for inclusion according to the above criteria, assessed risk of bias for each trial, and performed data extraction. We utilized an intention-to-treat analysis strategy. MAIN RESULTS: We identified one RCT that involved 40 participants, and addressed the timing of surgery for people with recently symptomatic carotid artery stenosis. It compared very early surgery with surgery performed after 14 days of the last symptomatic event. The overall quality of the evidence was very low, due to the small number of participants from only one trial, and missing outcome data. We found no statistically significant difference between the effects of very early or delayed surgery in reducing the combined risk of stroke and death within 30 days of surgery (risk ratio (RR) 3.32; confidence interval (CI) 0.38 to 29.23; very low-quality evidence), or the combined risk of perioperative death and stroke (RR 0.47; CI 0.14 to 1.58; very low-quality evidence). To date, no results are available to confirm the optimal timing for surgery. AUTHORS CONCLUSIONS: There is currently no high-quality evidence available to support either very early or delayed cerebral revascularization after a recent ischemic stroke. Hence, further randomized trials to identify which patients should undergo very urgent revascularization are needed. Future studies should stratify participants by age group, sex, grade of ischemia, and degree of stenosis. Currently, there is one ongoing RCT that is examining the timing of cerebral revascularization.

Immediate versus delayed treatment for recently symptomatic carotid artery stenosis.

BACKGROUND:: The timing of surgery for recently symptomatic carotid artery stenosis remains controversial. Early cerebral revascularization may prevent a disabling or fatal ischemic recurrence, but it may also increase the risk of hemorrhagic transformation, or of dislodging a thrombus. This review examined the randomized controlled evidence that addressed whether the increased risk of recurrent events outweighed the increased benefit of an earlier intervention. OBJECTIVES:: To assess the risks and benefits of performing very early cerebral revascularization (within two days) compared with delayed treatment (after two days) for people with recently symptomatic carotid artery stenosis. METHODS:: Search methods: We searched the Cochrane Stroke Group Trials Register in January 2016, the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2016, issue 1), MEDLINE (1948 to 26 January 2016), EMBASE (1974 to 26 January 2016), LILACS (1982 to 26 January 2016), and trial registers (from inception to 26 January 2016). We also handsearched conference proceedings and journals, and searched reference lists. There were no language restrictions. We contacted colleagues and pharmaceutical companies to identify further studies and unpublished trials Selection criteria: All completed, truly randomized trials (RCT) that compared very early cerebral revascularization (within two days) with delayed treatment (after two days) for people with recently symptomatic carotid artery stenosis.Data collection and analysis: We independently selected trials for inclusion according to the above criteria, assessed risk of bias for each trial, and performed data extraction. We utilized an intention-to-treat analysis strategy. MAIN RESULTS:: We identified one RCT that involved 40 participants, and addressed the timing of surgery for people with recently symptomatic carotid artery stenosis. It compared very early surgery with surgery performed after 14 days of the last symptomatic event. The overall quality of the evidence was very low, due to the small number of participants from only one trial, and missing outcome data. We found no statistically significant difference between the effects of very early or delayed surgery in reducing the combined risk of stroke and death within 30 days of surgery (risk ratio (RR) 3.32; confidence interval (CI) 0.38 to 29.23; very low-quality evidence), or the combined risk of perioperative death and stroke (RR 0.47; CI 0.14 to 1.58; very low-quality evidence). To date, no results are available to confirm the optimal timing for surgery. AUTHORS CONCLUSIONS:: There is currently no high-quality evidence available to support either very early or delayed cerebral revascularization after a recent ischemic stroke. Hence, further randomized trials to identify which patients should undergo very urgent revascularization are needed. Future studies should stratify participants by age group, sex, grade of ischemia, and degree of stenosis. Currently, there is one ongoing RCT that is examining the timing of cerebral revascularization.

Long-segment thoracoabdominal aortic coarctation in a child with Down syndrome.

Midaortic syndrome is a rare vascular anomaly characterized by coarctation of the descending thoracic and abdominal aorta. Down syndrome is associated with multiple congenital cardiac malformations but is rarely associated with developmental vascular anomalies. Midaortic syndrome may result in severe renovascular hypertension that requires early intervention to prevent life-threatening complications. We report a child with Down syndrome who presented with occlusion of the aorta and was treated with aortic bypass. More than 4 years after the procedure, the patient's renal function remains normal, and there is no evidence of recurrent hypertension. Long-term follow-up is important to assess the benefits of surgical repair.

Vascular anastomosis for paediatric renal transplantation and new strategy in low-weight children.

The technical aspects of RT in low-weight children should be specific, particularly with regard to VA. This retrospective study assesses the main VA options in paediatric RTs and proposes a new strategy for renal artery trajectory when using the Ao and the right iVC. The sample included 81 patients and was categorized into a group of children weighing <16 kg and the other group of children weighing 16 kg or more. The smaller children received the graft predominantly on the Ao and iVC (63%); however, the VA options varied in children weighing more than 16 kg, with anastomoses predominantly to the common iliac vessels (46%). In the first group, when the Ao was the selected vessel for anastomosis on the right side, the trajectory adopted for the transplanted kidney artery was posterior to the iVC. This strategy may reduce the risk of compression of the iVC by the renal artery of the donor kidney and may reconstitute the normal anatomy of the renal artery. Moreover, it did not represent a risk factor for graft loss in this sample.

Impact of angiogenic therapy in the treatment of critical lower limb ischemia in an animal model.

Angiogenic therapies for critical limb ischemia were tested in a mouse model. The mice were anesthetized and their femoral arteries were ligated. The animals were treated with bone marrow mononuclear cells (BMMCs) alone, BMMCs combined with plasmid vector encoding granulocyte macrophage colony-stimulating factor (GM-CSF), received no treatment, or no intervention (controls). The degree of ischemia was monitored for 4 weeks using a visual scale. Muscle atrophy and strength were assessed at 4 weeks postoperatively; the mice were then killed. In treated animals, total necrosis of the limb was not found, the weight of the gastrocnemius and quadriceps muscles was significantly higher, functional ability and tissue regeneration were significantly increased, and muscle impairment and adipocyte presence were significantly reduced compared with untreated animals. At inducing angiogenesis, the BMMCs alone was more effective than BMMCs combined with plasmid vector encoding GM-CSF. Treated animals showed increased angiogenesis compared with ischemic untreated ones.

Eficiência do laser diodo 980 nm em comparação à da glicose a 75 por cento na oclusão de veias da orelha de coelhos / The efficiency of the diode laser 980 nm compared to glucose 75 percent in occlusion of the veins in rabbit ears

CONTEXTO: Por ser o laser um método novo no tratamento das varizes, há muitos mitos e dúvidas com relação à sua eficácia; assim, surgiu a necessidade de compará-lo a substância esclerosante mais utilizada em nosso meio (glicose hipertônica). OBJETIVO: Comparar a eficiência do laser diodo 980 nm à glicose 75 por cento na oclusão de veias em orelha de coelho. MÉTODOS: Ensaio aleatório em animais de laboratório por 21 dias. A amostra consistiu de orelhas de coelhos machos adultos. Grupo L (laser): 15 orelhas tratadas com laser; grupo G (glicose 75 por cento): 15 orelhas tratadas com glicose a 75 por cento. Variáveis primárias: veias esclerosadas e/ou ocluídas. Variáveis complementares: volume da substância administrada, complicações e peso. O tamanho da amostra foi estimado em 30 orelhas. Foi realizado o teste exato de Fisher associado ao Risco Relativo (RR), calculando-se o intervalo de confiança (IC) de 95 por cento para as variáveis acima. RESULTADOS: A incidência de esclerose ou oclusão venosa no grupo G foi de 53 por cento (8/15; IC95 por cento: 27-79) e no grupo L, 20 por cento (3/15; IC95 por cento: 4-49). O p bicaudal foi de 0,1281, o RR usando a aproximação de Katz foi de 2,66; IC95 por cento: 0,87-8,15. CONCLUSÃO: A eficiência do laser diodo 980 nm em comparação à da glicose 75 por cento na oclusão de veias para o modelo experimental estudado foi equivalente.

BACKGROUND: The laser is a new treatment to varicose veins and there is several myths and doubts in relation to its efficacy; then, there is the need to compare it with the most commonly sclerosing solution (hypertonic glucose) used in our specialty. OBJECTIVE: To compare the efficiency of the diode laser 980nm to the glucose 75 percent in the occlusion of veins from the ear of rabbits. METHODS: Aleatory trial in laboratory animals during 21 days. The sample consisted of ears from male adult rabbits. Group L (laser): 15 ears treated with laser; group G (glucose 75 percent): 15 ears treated with glucose 75 percent. Primary variables: sclerotic and/or occluded veins. Complementary variables: volume of the managed substance, complications and weight of rabbit. The sample size was estimated in 30 ears. The statistical analysis was carried out by Fisher''s exact test associated to the Relative Risk (RR), calculating the confidence interval of 95 percent for the mentioned variables. RESULTS: The incidence of sclerosis or venous occlusion in group G was 53 percent (8/15; 95 percentCI: 27-79) and in group L was 20 percent (3/15; 95 percent CI: 4-49). Two-tailed p was 0.1281, RR using the approximation of Katz was 2.66; 95 percentCI: 0.87-8.15. CONCLUSION: The efficiency of the diode laser 980 nm in comparison to glucose 75 percent in occlusion of veins in this experimental model was equivalent.

Microcirculatory effects of local and remote ischemic preconditioning in supraceliac aortic clamping.

INTRODUCTION: Supraceliac aortic clamping in major vascular procedures promotes splanchnic ischemia and reperfusion (I/R) injury that may induce endothelial dysfunction, widespread inflammation, multiorgan dysfunction, and death. We tested the hypothesis that local or remote ischemic preconditioning (IPC) may be protective against injury after supraceliac aortic clamping through the modulation of mesenteric leukocyte-endothelial interactions, as evaluated with intravital microscopy and expression of adhesion molecules. METHODS: Fifty-six male Wistar rats (weight, 190 to 250 g), were divided into four groups of 14 rats each: control-sham surgery without aortic occlusion; I/R through supraceliac aortic occlusion for 20 minutes, followed by 120 minutes of reperfusion; local IPC through supraceliac aortic occlusion for two cycles of 5 minutes of ischemia and 5 minutes of reperfusion, followed by the same protocol of the IR group; remote IPC through infrarenal aortic occlusion for two cycles of 10 minutes of ischemia and 10 minutes of reperfusion, followed by the same protocol of the IR group. Seven animals per group were used to evaluate in vivo leukocyte-endothelial interactions in postcapillary venules with intravital microscopy and another seven animals per group were used to collect mesentery samples for immunohistochemistry demonstration of adhesion molecules expression. RESULTS: Supraceliac aortic occlusion increased the number of rolling leukocytes with slower velocities and increased the number of adherent leukocytes to the venular surface and leukocyte migration to the interstitium. The expression of P-selectin, E-selectin, and intercellular adhesion molecule-1 was also increased significantly after I/R. Local or remote IPC reduced the leukocyte recruitment in vivo and normalized the expression of adhesion molecules. CONCLUSIONS: Local or remote IPC reduces endothelial dysfunction on mesenteric microcirculation caused by I/R injury after supraceliac aortic clamping.

Synergistic effect of vascular endothelial growth factor and granulocyte colony-stimulating factor double gene therapy in mouse limb ischemia.

BACKGROUND: Vascular endothelial growth factor (VEGF) has mostly been tested to treat ischemic diseases, although the outcomes obtained are not satisfactory. Our hypothesis is that the local transient expression of VEGF and stem cell mobilizer granulocyte colony-stimulating factor (G-CSF) genes in ischemic limbs can complement their activities and be more efficient for limb recovery. METHODS: Limb ischemia was surgically induced in mice and 50 microg of VEGF and/or G-CSF genes were locally transferred by electroporation. After 3-4 weeks, evidence of necrosis by visual inspection, capillary density, muscle mass, muscle force and hematopoietic cell mobilization were evaluated. RESULTS: After 4 weeks, 70% and 90% of the animals of the ischemic group (IG) and VEGF-treated group (VG), respectively, presented limb necrosis, in contrast to only 10% observed in the group of mice treated with both VEGF and G-CSF genes (VGG). Recovery of muscle mass and muscle force was higher than 60% in the VGG compared to the non-ischemic group. The mobilization of Sca1+ cells and neutrophils was also higher in the VGG, which may explain the lower level of necrosis observed in this group (22%, in contrast to 70% in the IG). Capillary density and degree of fibrosis were determined in weeks 3 and 4, and also showed a clear benefit as a result of the use of the G-CSF and VEGF genes together. CONCLUSIONS: Gene therapy using VEGF and G-CSF demonstrated a synergistic effect promoting vessel and tissue repair in mouse hind limb ischemia.

Granulocyte-macrophage colony-stimulating factor gene based therapy for acute limb ischemia in a mouse model.

BACKGROUND: Granulocyte-colony-stimulating factor (GM-CSF) is a pleiotropic factor for hematopoiesis that stimulates myeloblasts, monoblasts and mobilization of bone marrow stem cells. Therefore, the GM-CSF gene is a potential candidate for vessel formation and tissue remodeling in the treatment of ischemic diseases. METHODS: A new mouse limb ischemia was established by surgery and gene transfer was performed by injection of 100 microg of a plasmid carrying GM-CSF. Muscle force and weight, histology, capillary density, circulating stem cells and monocytes were determined after 3-4 weeks. RESULTS: More than 60% of nontreated ischemic animals showed gangrene below the heel after 4 weeks, whereas the GM-CSF gene-treated animals showed only darkening of nails or toes. These animals demonstrated a full recovery of the affected muscles in terms of weight, force and muscle fiber structure, but the muscles of nontreated ischemic animals lost approximately 50% weight, 86% force and their regular structure. When the GM-CSF gene was injected into the contralateral limb, only partial loss was observed, demonstrating a distant effect of GM-CSF. The capillary density in the GM-CSF-treated group was 52% higher in relation to the nontreated group. Blood analysis by flow cytometry showed that the GM-CSF-treated group had 10-20% higher levels of circulating monocytes and Sca-1(+). CONCLUSIONS: We conclude that the direct administration of GM-CSF gene in limb ischemia had a strong therapeutic effect because it promoted the recovery of muscle mass, force and structure by mobilizing therapeutic cells and augmenting the number of vessels.

Long-term effects for acute phase myocardial infarct VEGF165 gene transfer cardiac extracellular matrix remodeling.

BACKGROUND: Cardiac remodeling is ultimately regulated by components of the extracellular matrix (ECM). We investigated the important role that growth factors play in the regulation of ECM remodeling that occurs as a consequence of myocardium damage. METHODS AND RESULTS: Rats were submitted to the ligation of the left anterior coronary artery and pcDNA3-vascular endothelial growth factor (VEGF)(165) was immediately injected intramyocardially in the treated group. The animals were divided into large size myocardium infarction (LMI) and small size myocardium infarction, with or without gene transfer. The plasmid-containing DNA encoding VEGF(165) was injected into the cardiac muscle and its effect was observed on the ECM components. Glycosaminoglycans were identified and quantified by agarose gel based electrophoresis and ELISA as well as immunocytochemistry to examine specific cathepsin B, heparanase, and syndecan-4 changes. The amounts of hyaluronic acid (HA; p < 0.005), DS, chondroitin sulfate, and heparan sulfate (p < 0.001) were significantly increased in the LMI treated group in comparison to the other groups, which correlates with the decrease in the expression of heparanase. A decrease in the molecular mass of HA was found in the scar tissue of treated group. CONCLUSIONS: The data obtained strongly support the idea that changes in the ECM and its components are important determinants of cardiac remodeling after myocardium infarct and may be essential for inflammatory response and attempt to stabilize the damage and provide a compensatory mechanisms to maintain cardiac output since the ECM components analyzed are involved with angiogenesis, cell proliferation and differentiation.

Kidney weight and volume among living donors in Brazil.

CONTEXT AND OBJECTIVE: The present study was performed to measure kidney weight and volume among living donors of both sexes in Brazil. DESIGN AND SETTING: This was a cross-sectional survey carried out between December 2001 and August 2004. METHODS: Kidney transplantations from 219 living donors were analyzed for this study. The kidneys were weighed in grams on a single-pan digital balance just after drainage of the perfusion fluid and removal of the perirenal fat. The kidney volume was determined in milliliters by water displacement. RESULTS: The mean age at nephroureterectomy was 44 +/- 9.5. The donor organs came from the left side in 172 cases and from the right side in 47 cases. The weights and volumes of the right and left kidneys were, respectively, 169.83 +/- 29.91 g and 157.38 +/- 31.84 ml; and 173.00 +/- 33.52 g and 160.34 +/- 34.40 ml. The differences between the sides were not significant. CONCLUSIONS: According to the present study, kidney weight cannot be the only factor determining the side on which nephroureterectomy is performed, because of the lack of statistical significance between the two sides. On average, females donate lower nephron doses than males do, which could in some transplants result in allograft damage.

Kidney weight and volume among living donors in Brazil

CONTEXT AND OBJECTIVE: The present study was performed to measure kidney weight and volume among living donors of both sexes in Brazil. DESIGN AND SETTING: This was a cross-sectional survey carried out between December 2001 and August 2004. METHODS: Kidney transplantations from 219 living donors were analyzed for this study. The kidneys were weighed in grams on a single-pan digital balance just after drainage of the perfusion fluid and removal of the perirenal fat. The kidney volume was determined in milliliters by water displacement. RESULTS: The mean age at nephroureterectomy was 44 ± 9.5. The donor organs came from the left side in 172 cases and from the right side in 47 cases. The weights and volumes of the right and left kidneys were, respectively, 169.83 ± 29.91 g and 157.38 ± 31.84 ml; and 173.00 ± 33.52 g and 160.34 ± 34.40 ml. The differences between the sides were not significant. CONCLUSIONS: According to the present study, kidney weight cannot be the only factor determining the side on which nephroureterectomy is performed, because of the lack of statistical significance between the two sides. On average, females donate lower nephron doses than males do, which could in some transplants result in allograft damage.

CONTEXTO E OBJETIVO: O atual estudo foi realizado para medir massa e volume de rins de doadores vivos brasileiros de ambos os sexos. TIPO DE ESTUDO E LOCAL: Estudo transversal executado entre dezembro de 2001 e agosto de 2004, foram incluídos no estudo, 219 nefroureterectomias renais de doadores vivos. MÉTODOS: O rim do doador foi pesado em gramas em uma balança digital, imediatamente após a retirada da gordura peri-renal e drenagem do fluído perfusional. O volume renal foi determinado em mililitros por deslocamento de água. RESULTADOS: A média de idade dos doadores foi de 44 ± 9,5 anos. Foram realizadas 172 (78,54 por cento) nefroureterectomias no lado esquerdo e 47 (21,46 por cento) no lado direito. O peso renal do lado direito foi de 169,83 ± 29,91 g; enquanto que o peso renal do lado esquerdo foi de 173,00 ± 33,52 g. O volume renal do lado direito foi de 157,38 ± 31,84 ml; do lado esquerdo, 160,34 ± 34,40 ml. Não havendo diferença significativa entre os lados. CONCLUSÕES: De acordo com o estudo atual, não há diferença significativa entre o peso renal do lado direito e esquerdo, não podendo ser o peso renal um fator de escolha do lado da nefroureterectomia. Além disso, o estudo proporciona uma sobre o peso e volume de rins de brasileiros adultos de ambos os sexos.

Traumatismos de veia cava inferior / Inferior vena cava injuries

OBJETIVO: Avaliar a incidência, o perfil clínico e as estratégias operatórias dos ferimentos de Veia Cava Inferior (VCI). MÉTODOS: Foram analisados retrospectivamente os prontuários de 76 doentes com ferimento de VCI atendidos nos dois prontossocorros de Manaus, no período de janeiro de 1997 a julho de 2002. Mecanismo de lesão, mortalidade, estado hemodinâmico, índice de trauma abdominal penetrante (PATI), achados intra-operatórios e conduta cirúrgica foram estudados. RESULTADOS: Quarenta e nove (65 por cento) doentes sofreram lesão por arma branca, 26 (34 por cento) por arma de fogo e um por traumatismo abdominal fechado. Quarenta e um (54 por cento) doentes sobreviveram. Quase todos chegaram acordados, entretanto 40 por cento estavam hipotensos (pressão arterial sistólica < 70mmHg). O índice de trauma abdominal penetrante (PATI) médio foi maior que 40. A laparotomia, todos demonstraram sangramento retroperitoneal ativo ou hematoma retroperitoneal em expansão. Vinte e um pacientes possuíam lesão de VCI retro-hepática, enquanto nos outros 55 a lesão era infra-hepática. O reparo operatório predominante foi a venorrafia lateral em 65 doentes. Houve necessidade de tóraco-freno-laparotomia em quatro doentes do total de oito doentes que foram à toracotomia direita por lesão retro-hepática. Foram realizados shunts átrio-cavais em seis doentes, dos quais três sobreviveram. CONCLUSÕES: O ferimento de VCI é uma lesão de alta letalidade e possui uma relação intrínseca com a violência urbana. A sobrevivência depende de uma imediata e vigorosa reposição de volume, um manejo operatório adequado e todo esforço em evitar-se hipotermia.