Accidental guide wire migration and late percutaneous externalization after central venous catheterization.

A 70-year-old man was admitted to the emergency department with recent spontaneous externalization of a metallic device from his right inner thigh. He had been experiencing mild local pain for 2 weeks and had a recent hospitalization due to cardiogenic hemodynamic instability, requiring a central venous catheter placement in his right internal jugular vein 3 months earlier. Doppler ultrasound confirmed the intravascular foreign body hypothesis as a guidewire was identified inside the right femoral vein, associated with femoropopliteal venous thrombosis. The guidewire was successfully removed percutaneously through simple manual traction guided by radioscopy. The patient was discharged the following day on oral anticoagulation with rivaroxaban. On outpatient follow-up 4 weeks post discharge, he had no complaints in the right lower limb except for slight swelling. Central venous catheterization is a common invasive procedure that, although unquestionably safe and well stablished in medical practice, can lead to serious complications when performed without proper technique.

Thromboprophylaxis in lower limb varicose vein surgery in Brazil.

Background: Despite all the investment in primary venous thromboembolism (VTE) prophylaxis for surgical patients in recent years, there are still no specific guidelines for those who undergo procedures to treat lower limb varicose veins. Objectives: To evaluate the profile of VTE prophylaxis practices among Brazilian vascular surgeons conducting lower limb varicose vein procedures. Methods: Survey design, sending an electronic questionnaire to Brazilian vascular surgeons. Respondents were divided between those who perform saphenous vein treatment with conventional surgery and those who perform thermoablation for the purpose of comparison between groups. Results: Of 765 respondents, 405 (53%) treat saphenous veins with conventional surgery for, 44 (6%) with foam, and 199 (26%) with thermoablation (endolaser or radiofrequency). Surgeons who perform thermoablation prescribed more pharmacoprophylaxis after varicose vein surgery than those who perform conventional surgery (67/199, 34% vs. 112/405, 28%; p = 0.002). The thermoablation group stratifies patients for thromboembolism risk more frequently than the conventional surgery group (102/199, 51% vs. 179/405, 44%; p = 0.004). Both groups use enoxaparin as the most frequent drug for prophylaxis, but the thermoablation group uses proportionally more direct oral anticoagulants than the conventional surgery group (26% vs. 10%, p<0.001). Conclusions: Brazilian vascular surgeons who perform saphenous vein treatment by thermoablation prescribe pharmacoprophylaxis more frequently and for a longer period than those who use conventional surgery.

Tromboprofilaxia na cirurgia de varizes dos membros inferiores no Brasil / Thromboprophylaxis in lower limb varicose vein surgery in Brazil

Resumo Contexto Apesar de todo o investimento na profilaxia primária do tromboembolismo venoso (TEV) em pacientes cirúrgicos nos últimos anos, ainda não existem diretrizes específicas para aqueles que serão submetidos a procedimentos para tratamento de varizes de membros inferiores. Objetivos Avaliar o perfil de conduta de profilaxia do TEV pelos cirurgiões vasculares brasileiros para procedimentos de tratamento de varizes de membros inferiores. Métodos Pesquisa de levantamento por envio de questionário eletrônico a cirurgiões vasculares brasileiros. Os respondentes foram divididos entre os que realizam tratamento de veias safenas por cirurgia convencional e os que realizam termoablação para fim de comparação entre os grupos. Resultados Entre os 765 respondentes, o tratamento de escolha das veias safenas foi a cirurgia convencional para 405 (53%), espuma ecoguiada para 44 (6%) e termoablação (endolaser ou radiofrequência) para 199 (26%). Os cirurgiões que realizam termoablação prescrevem mais farmacoprofilaxia após o procedimento que aqueles que preferem cirurgia convencional (67/199, 34% vs. 112/405, 28%; p = 0,002). O grupo termoablação estratifica o paciente quanto ao risco de TEV com mais frequência que o grupo cirurgia convencional (102/199, 51% vs. 179/405, 44%; p =0,004). Ambos os grupos usam mais frequentemente enoxaparina como medicação para profilaxia, porém o grupo termoablação usa mais anticoagulantes orais diretos proporcionalmente que o grupo cirurgia convencional (26% vs. 10%, p < 0,001). Conclusões Cirurgiões vasculares brasileiros que fizeram o tratamento de veias safenas por termoablação prescrevem farmacoprofilaxia com maior frequência e por um período mais prolongado do que os que realizaram o tratamento por cirurgia convencional.

Abstract Background Despite all the investment in primary venous thromboembolism (VTE) prophylaxis for surgical patients in recent years, there are still no specific guidelines for those who undergo procedures to treat lower limb varicose veins. Objectives To evaluate the profile of VTE prophylaxis practices among Brazilian vascular surgeons conducting lower limb varicose vein procedures. Methods Survey design, sending an electronic questionnaire to Brazilian vascular surgeons. Respondents were divided between those who perform saphenous vein treatment with conventional surgery and those who perform thermoablation for the purpose of comparison between groups. Results Of 765 respondents, 405 (53%) treat saphenous veins with conventional surgery for, 44 (6%) with foam, and 199 (26%) with thermoablation (endolaser or radiofrequency). Surgeons who perform thermoablation prescribed more pharmacoprophylaxis after varicose vein surgery than those who perform conventional surgery (67/199, 34% vs. 112/405, 28%; p = 0.002). The thermoablation group stratifies patients for thromboembolism risk more frequently than the conventional surgery group (102/199, 51% vs. 179/405, 44%; p = 0.004). Both groups use enoxaparin as the most frequent drug for prophylaxis, but the thermoablation group uses proportionally more direct oral anticoagulants than the conventional surgery group (26% vs. 10%, p<0.001). Conclusions Brazilian vascular surgeons who perform saphenous vein treatment by thermoablation prescribe pharmacoprophylaxis more frequently and for a longer period than those who use conventional surgery.

Evaluation of endolaser thermoablation of the small saphenous vein under local anesthesia.

BACKGROUND: The small saphenous vein (SSV) is affected in 15% of chronic venous insufficiency (CVI) cases. Conventional surgery is the standard technique for treatment of SSV insufficiency, but sural nerve injury is a complication of great concern. Endovenous laser ablation is a surgical technique for treatment of CVI that is considered likely to reduce morbidity and mortality. OBJECTIVES: To evaluate patients with CVI undergoing endovenous laser ablation of the SSV at least 30 days after the procedure. METHODS: We analyzed 54 lower extremities in 46 patients scheduled for 1470-nm endovenous laser ablation under local anesthesia to treat CVI in a tertiary hospital. Patients were evaluated preoperatively, intraoperatively, and postoperatively over 30 days with clinical examination, physical examination, and ultrasound. RESULTS: In the 54 lower extremities treated, there was a significant difference (p < 0.003) in terms of reduction in the diameter of treated veins (6.37 mm preoperatively and 5.15 mm on the 30th postoperative day) and improvement in the venous clinical severity score (VCSS) (means of 8.02 preoperative and 6.11 on the 30th postoperative day) (95%CI, 5.01-7.21) (p < 0.02). Postoperative complications such as paresthesia and phlebitis were present and diagnosed in 5 and 3 patients, respectively, but did not affect their quality of life or routine activities. CONCLUSIONS: Intravenous laser ablation of the SSV proved to be safe and effective for reducing clinical symptoms and improving quality of life.

Limb ischemia in patients with COVID-19.

This narrative review covers the life-threatening thromboembolic events associated with SARS-CoV-2 infection/COVID-19. It addresses the physical changes that cause vascular and arterial damage to limbs, laboratory management of coagulation, and management of anticoagulation. COVID-19's relationship with deep venous thrombosis and arterial thrombosis is also emphasized. The main thromboembolic events described in the literature are illustrated with examples from our experience with COVID-19 patients.

Esta revisão narrativa abrange os eventos tromboembólicos com risco de vida associados a infecção por SARS-CoV-2/COVID-19. Aborda as mudanças físicas que causam danos vasculares e arteriais aos membros, o manejo laboratorial da coagulação e o manejo da anticoagulação. A relação de COVID-19 com trombose venosa profunda e trombose arterial também é enfatizada. Os principais eventos tromboembólicos descritos na literatura são ilustrados a partir de nossa experiência com pacientes COVID-19.

Endovascular treatment of subclavian artery injury with a complex post-traumatic fistula: Case report.

BACKGROUND: Endovascular treatment in trauma is a promising strategy to reduce perioperative morbidity and mortality. We report the case of a gunshot wound causing an initially undiagnosed subclavian artery injury, with delayed progression to a complex, difficult-to-manage arteriovenous (AV) fistula. Placement of an encapsulated endovascular stent graft resolved the primary lesion, but persistent cervical arteriovenous communications were only repaired after multiple, sequential embolization procedures. REPORT: A 25-year-old male sustained a gunshot wound to the right neck. Initial treatment failed to identify any vascular injury, and the patient was discharged. Three weeks later, he presented to our facility with headache and a palpable right-sided cervical thrill. Arteriography showed contrast extravasation from the right subclavian artery and an AV fistula with the ipsilateral internal jugular vein. The arterial injury was repaired with an encapsulated stent graft, but residual contrast leak persisted on follow-up angiography. Three months after the first intervention, cervical thrill was still present; a right vertebral-right internal jugular AV fistula was identified and repaired by distal coil embolization. One month later, persistent symptoms prompted repeat arteriography, which again identified contrast extravasation, now involving the thyrocervical trunk. Selective thyrocervical embolization was ultimately successful, with resolution of symptoms and no further evidence of contrast leak. CONCLUSION: Delayed management of neck trauma can be challenging due to neovascularization, which hinders open repair in this delicate region. Post-traumatic arteriovenous fistulas are thus a particularly fearsome complication, and can be very difficult to approach; as in our patient, multiple interventions may be required. This case highlights the importance of detecting vascular trauma as early as possible, as a delay in diagnosis can hinder treatment and eventuate challenging late complications. Further studies are needed to demonstrate the long-term benefits of endovascular management of complex vascular injuries of the neck region.

Avaliação da termoablação com endolaser da veia safena parva com anestesia local / Evaluation of endolaser thermoablation of the small saphenous vein under local anesthesia

Resumo Contexto Na insuficiência venosa crônica (IVC), a veia safena parva (VSP) é afetada em 15% dos casos. A cirurgia convencional é a técnica padrão para o tratamento da insuficiência da VSP, sendo a lesão no nervo sural uma complicação bastante temida. O tratamento de termoablação com endolaser tende a ser um método cirúrgico que diminui complicações da terapia cirúrgica da IVC. Objetivos Avaliar os pacientes com IVC submetidos à terapia por endolaser da VSP ao menos 30 dias após o procedimento. Métodos Foram analisados 54 membros inferiores de 46 pacientes submetidos à terapia por endolaser 1470 nm, sob anestesia local, para o tratamento da IVC em um hospital terciário. Os pacientes foram avaliados no período pré-operatório, intraoperatório e pós-operatório de 30 dias, através da clínica, exame físico e achados ecográficos. Resultados Nos 54 membros inferiores submetidos ao tratamento, comparando-se o período pré-operatório e o 30º dia pós-operatório, houve diferença significativa (p < 0,003) na redução do diâmetro da VSP tratada (6,37 mm pré-operatório e 5,15 mm no 30º dia pós-operatório) (IC95% 4,58-5,72) e na melhora do escore de gravidade clínica venosa (VCSS) (média de 8,02 pré-operatório e 6,11 no 30º dia pós-operatório) (IC95% 5,01-7,21) (p < 0,02). Complicações pós-operatórias, como parestesia e flebite, estiveram presentes e foram diagnosticadas em cinco e três pacientes, respectivamente, sem significar alteração na qualidade de vida e nas atividades de rotina. Conclusões A técnica de termoablação com laser da VSP mostrou-se segura e eficaz na redução dos sintomas clínicos e na melhora da qualidade de vida.

Abstract Background The small saphenous vein (SSV) is affected in 15% of chronic venous insufficiency (CVI) cases. Conventional surgery is the standard technique for treatment of SSV insufficiency, but sural nerve injury is a complication of great concern. Endovenous laser ablation is a surgical technique for treatment of CVI that is considered likely to reduce morbidity and mortality. Objectives To evaluate patients with CVI undergoing endovenous laser ablation of the SSV at least 30 days after the procedure. Methods We analyzed 54 lower extremities in 46 patients scheduled for 1470-nm endovenous laser ablation under local anesthesia to treat CVI in a tertiary hospital. Patients were evaluated preoperatively, intraoperatively, and postoperatively over 30 days with clinical examination, physical examination, and ultrasound. Results In the 54 lower extremities treated, there was a significant difference (p < 0.003) in terms of reduction in the diameter of treated veins (6.37 mm preoperatively and 5.15 mm on the 30th postoperative day) and improvement in the venous clinical severity score (VCSS) (means of 8.02 preoperative and 6.11 on the 30th postoperative day) (95%CI, 5.01—7.21) (p < 0.02). Postoperative complications such as paresthesia and phlebitis were present and diagnosed in 5 and 3 patients, respectively, but did not affect their quality of life or routine activities. Conclusions Intravenous laser ablation of the SSV proved to be safe and effective for reducing clinical symptoms and improving quality of life.

Limb ischemia in patients with COVID-19 / Isquemia de membros em pacientes com COVID-19

Abstract This narrative review covers the life-threatening thromboembolic events associated with SARS-CoV-2 infection/COVID-19. It addresses the physical changes that cause vascular and arterial damage to limbs, laboratory management of coagulation, and management of anticoagulation. COVID-19's relationship with deep venous thrombosis and arterial thrombosis is also emphasized. The main thromboembolic events described in the literature are illustrated with examples from our experience with COVID-19 patients.

Resumo Esta revisão narrativa abrange os eventos tromboembólicos com risco de vida associados a infecção por SARS-CoV-2/COVID-19. Aborda as mudanças físicas que causam danos vasculares e arteriais aos membros, o manejo laboratorial da coagulação e o manejo da anticoagulação. A relação de COVID-19 com trombose venosa profunda e trombose arterial também é enfatizada. Os principais eventos tromboembólicos descritos na literatura são ilustrados a partir de nossa experiência com pacientes COVID-19.

Tratamento de linfocele mediante ecoescleroterapia com polidocanol: relato de casos e revisão / Polidocanol echosclerotherapy treatment for lymphocele: case report and review

Resumo A formação de linfocele, resultante da transecção dos canais linfáticos durante procedimentos cirúrgicos ou traumas, é relativamente comum, sendo relatada em aproximadamente 30% dos pós-operatórios de ressecção de linfonodos. Ela pode evoluir assintomática ou pode apresentar complicações, como dor, infecção secundária, compressão de vasos sanguíneos, a qual evolui para estase, trombose e edema. Seu tratamento ainda é de difícil consenso. Este artigo propõe descrever três casos em que o tratamento foi realizado a partir de ecoescleroterapia com polidocanol. Sua relevância está na escassez de relatos na literatura.

Abstract Formation of lymphocele secondary to transection of lymphatic channels during surgical procedures or traumas is relatively common and is reported in the postoperative period of approximately 30% of lymph node resection procedures. The condition may be asymptomatic or can present with complications such as pain, secondary infection, and compression of blood vessels, which can cause stasis, thrombosis, and edema. There is no consensus on treatment. This article describes three cases in which treatment was provided using polidocanol echosclerotherapy. Its relevance lies in the scarcity of reports in the literature.

Polidocanol echosclerotherapy treatment for lymphocele: case report and review.

Formation of lymphocele secondary to transection of lymphatic channels during surgical procedures or traumas is relatively common and is reported in the postoperative period of approximately 30% of lymph node resection procedures. The condition may be asymptomatic or can present with complications such as pain, secondary infection, and compression of blood vessels, which can cause stasis, thrombosis, and edema. There is no consensus on treatment. This article describes three cases in which treatment was provided using polidocanol echosclerotherapy. Its relevance lies in the scarcity of reports in the literature.

Fórum Vascular: inteligência coletiva na resolução de casos clínicos vasculares / Vascular Forum: collective intelligence in the resolution of vascular clinical cases

Contexto: A inteligência coletiva tem extrema importância em grupos coletivos de discussão de casos clínicos médicos, auxiliando tanto os profissionais na pronta tomada de decisão como seus pacientes. Objetivos: Avaliar a resolutividade e as características das discussões clínicas realizadas em grupo fechado de mensagens instantâneas e sua aplicabilidade clínica. Métodos: Análise retrospectiva de discussões clínicas e eventos no Fórum Vascular, grupo aberto para especialistas em dispositivos móveis. Resultados: No período de julho de 2015 a julho de 2017, foram discutidos 1.013 assuntos, com 680 membros. Desses assuntos, 26 (2,57%) foram curiosidades, 101 (9,97%) foram dúvidas de diagnóstico, 492 (48,57%) foram dúvidas de tratamento, 205 (20,24%) foram dúvidas gerais e 189 (17,5%) foram relatos de casos. O número médio de interações por evento foi de 16,599 (±1,366). O tempo médio para a primeira resposta foi de 42,14 min (±7,55). Os assuntos discutidos foram 358 casos com miscelânea, 336 casos venosos, 15 casos linfáticos e 304 casos arteriais, totalizando 15.985 respostas. Conclusões: A interação entre especialistas utilizando a tecnologia de troca de mensagens instantâneas mostrou-se capaz de levantar discussões e abordagens rapidamente. A resolutividade, considerada o tempo da primeira resposta correta, também foi alta. O Fórum Vascular evidenciou­se uma ferramenta de grande valia clínica para seus participantes, confirmando a importância da inteligência coletiva na área médica

Background: Collective intelligence is extremely important in collective groups that discuss clinical medical cases, assisting professionals in their decision-making processes, and consequently, helping their patients. Objectives: To evaluate the rate of resolution and characteristics of the clinical discussions carried out in a private instant messaging group and its clinical applicability. Methods: Retrospective analysis of clinical discussions and events on the Vascular Forum, an open group for specialists accessed with mobile devices. Results: From July 2015 to July 2017, 1013 subjects were discussed among 680 members. Twenty-six (2.57%) of these subjects were curiosities, 101 (9.97%) related to diagnostic doubts, 492 (48.57%) to treatment doubts, and 205 (20.24%) to general doubts, while 189 (17.5%) were case reports. The mean number of interactions per event was 16.599 (±1.366). The mean time from posting of a new subject to the first reply was 42.14 (±7.55) min. The subject discussed was miscellaneous in 358 cases, venous in 336 cases, lymphatic in 15 cases, and arterial in 304 cases and the total number of replies was 15985. Conclusions: Interaction between experts using instant messaging technology proved capable of raising subjects for discussion and eliciting management approaches quickly. The rate of resolution, defined as the time taken for the first correct answer to be posted, was also high. The Vascular Forum proved to be a tool of great clinical value for its participants, confirming the importance of collective intelligence in medicine

Vascular Forum: collective intelligence in the resolution of vascular clinical cases.

BACKGROUND: Collective intelligence is extremely important in collective groups that discuss clinical medical cases, assisting professionals in their decision-making processes, and consequently, helping their patients. OBJECTIVES: To evaluate the rate of resolution and characteristics of the clinical discussions carried out in a private instant messaging group and its clinical applicability. METHODS: Retrospective analysis of clinical discussions and events on the Vascular Forum, an open group for specialists accessed with mobile devices. RESULTS: From July 2015 to July 2017, 1013 subjects were discussed among 680 members. Twenty-six (2.57%) of these subjects were curiosities, 101 (9.97%) related to diagnostic doubts, 492 (48.57%) to treatment doubts, and 205 (20.24%) to general doubts, while 189 (17.5%) were case reports. The mean number of interactions per event was 16.599 (±1.366). The mean time from posting of a new subject to the first reply was 42.14 (±7.55) min. The subject discussed was miscellaneous in 358 cases, venous in 336 cases, lymphatic in 15 cases, and arterial in 304 cases and the total number of replies was 15985. CONCLUSIONS: Interaction between experts using instant messaging technology proved capable of raising subjects for discussion and eliciting management approaches quickly. The rate of resolution, defined as the time taken for the first correct answer to be posted, was also high. The Vascular Forum proved to be a tool of great clinical value for its participants, confirming the importance of collective intelligence in medicine.

Influência da termoablação com baixa e alta densidade de energia na junção safeno-femoral, utilizando laser endovenoso 1470nm / The influence of low- and high-energy-density intravenous laser ablation on the saphenofemoral junction, with 1470-nm laser

Contexto: Faz-se importante o conhecimento técnico dos ajustes de potência e de densidade de energia linear endovenosa (linear endovenous energy density, LEED) adequados para atingir o objetivo final da termoablação endovenosa (endovenous laser ablation, EVLA). Objetivos: Avaliar a influência de diferentes LEEDs em termos de patência e presença de refluxo, bem como determinar a evolução clínica. Métodos: Foram incluídas 60 veias safenas magnas (VSM). Os pacientes foram randomizados em dois grupos: EVLA com baixa potência (7 W e LEED de 20-40 J/cm) e com alta potência (15 W e LEED de 80-100 J/cm). O acompanhamento com eco-Doppler e escore de severidade clínica venoso (VCSS) foi realizado nos intervalos de 3-5 dias, 30 dias, 180 dias e 1 ano após o procedimento. Resultados: Dezoito pacientes (29 membros) tratados com 7W de potência e 13 pacientes (23 membros) com 15 W completaram o estudo. Não houve diferença significativa considerando idade, tempo de cirurgia e o uso de analgésicos, lateralidade, gênero e presença de comorbidades. O LEED médio foi de 33,54 J/cm no grupo de 7 W e de 88,66 J/cm no de 15 W. Ambos apresentaram melhora no VCSS, redução significativa dos diâmetros da JSF e ausência de diferença significativa quanto ao aumento do comprimento do coto da VSM e de refluxo após o tratamento. Conclusões: A utilização de maior densidade de energia mostrou-se mais efetiva em relação à estabilização do comprimento do coto da VSM e do refluxo em 6 meses. Fazem-se necessários estudos com um período de acompanhamento maior para fundamentar essa hipótese

Background: It is important to acquire technical knowledge about the power and linear endovenous energy density (LEED) settings needed to achieve the ultimate goal of endovenous laser ablation (EVLA). Objectives: To evaluate the influence of different LEEDs in terms of patency and presence of reflux and to determine clinical outcomes. Methods: Sixty great saphenous veins (GSVs) were included. Patients were randomized into 2 groups, low-power EVLA (7 W and LEED of 20-40 J/cm) and high-power EVLA (15 W and LEED of 80-100 J/cm). Patients were followed-up with duplex ultrasound and calculation of venous clinical severity score (VCSS) at 3-5 days, 30 days, 180 days, and 1 year after the procedure. Results: 18 patients (29 limbs) treated with 7 W of laser power and 13 patients (23 limbs) treated with 15 W of laser power completed the study. There was no significant difference regarding age, operating time, use of analgesics, laterality, sex, or presence of comorbidities. Mean LEED was 33.54 J/cm in the 7-W group and 88.66 J/cm in the 15-W group. Both groups exhibited improvements in VCSS and significant reductions in SFJ diameters, and there were no significant difference in increase of length of the GSV stump or rates of reflux after treatment. Conclusions: The higher energy density setting was more effective for stabilizing the length of the GSV stump and was associated with a lower incidence of reflux at 6 months. Further studies with a longer follow-up period are required to substantiate this hypothesis

Estudo comparativo da termoablação da veia safena magna na coxa, com e sem tumescência / Comparative study of great saphenous vein ablation in the thigh, with and without tumescence

Resumo Contexto O tratamento com laser endovenoso das veias safenas oferece ao paciente um procedimento com baixos índices de complicações, proporcionando retorno precoce à atividade ocupacional. Objetivo Comparar a formação de hematoma, a presença de parestesia no trajeto da veia safena magna (VSM) e a sua taxa de obliteração em 30 dias após a termoablação ao nível da coxa, utilizando ou não a tumescência e dois tipos de fibras. Métodos Estudo prospectivo em que foram analisados três grupos de pacientes submetidos a termoablação da VSM em coxa, utilizando comprimento de onda 1470 nm. No grupo 1, utilizou-se fibra convencional e tumescência; no grupo 2, fibra convencional sem tumescência; e no grupo 3, fibra dupla radial sem tumescência. Foram comparados, no período de 30 dias, a taxa de obliteração ao eco-Doppler, a ocorrência de parestesias e hematomas. Resultados Ao se comparar 90 VSMs de coxa submetidas a termoablação, obteve-se taxas de obliterações similares entre os grupos, sem diferença estatística. Nos grupos sem tumescência, ocorreu maior número de parestesias no trajeto da VSM na coxa no sétimo dia do que no grupo com tumescência, mas somente com significância estatística na comparação com o grupo da fibra convencional. Ocorreram hematomas em todos os grupos, sendo mais frequentes no grupo 1 (73,33%). Conclusões A realização da tumescência mostrou-se útil na prevenção de lesões neurológicas menores, mas não influenciou a ocorrência de hematomas e a taxa de oclusão da VSM na coxa em até 30 dias de sua termoablação.

Abstract Background Endovenous laser treatment of saphenous veins offers patients a procedure with low rates of complications and an early return to occupational activities. Objective To compare rates of formation of bruising, of paresthesia along the path of the great saphenous vein (GSV), and of GSV obliteration 30 days after thermal ablation in the thigh, performed with or without tumescence and using two different types of fiber. Methods This was a prospective study, analyzing three groups of patients who underwent GSV thermal ablation in the thigh, using a wavelength of 1470 nm. Patients in group 1 were treated with a conventional fiber using tumescence; those in group 2 were treated with a conventional fiber without using tumescence; and patients in group 3 were treated with a double radial fiber without tumescence. After 30 days, the rates of obliteration shown by Doppler ultrasonography, of paresthesias, and of bruising were compared. Results Comparison of the results of thermal ablation of 90 GSVs in the thigh revealed similar rates of obliteration, with no statistical differences. The rate of paresthesia along the path of the GSV in the thigh was higher in the groups without tumescence than in the group with tumescence, but the difference only attained statistical significance for the comparison with the group that was treated with the conventional fiber. There was bruising in all groups, with greater frequency in group 1 (73.33%). Conclusions Tumescence proved useful for preventing minor neurological injuries, but didn’t have any influence on the rates of bruising occurrence or of occlusion of the GSV in the thigh up to 30 days after thermal ablation.

Prevenção de tromboembolismo venoso em hospital com perfil oncológico: como melhorá-la? / How can prevention of venous thromboembolism be improved in a hospital with an oncological profile?

Resumo Contexto Complicações do tromboembolismo venoso são encontradas frequentemente em pacientes internados, tanto em condições clínicas quanto em pós-operatórios. Objetivo Verificar a quimioprofilaxia utilizada para tromboembolismo venoso em pacientes oncológicos internados, antes e após a realização de um programa de esclarecimento da sua importância. Métodos Estudo de corte transversal realizado em três momentos distintos: inicialmente antes do programa de conscientização da importância da profilaxia do tromboembolismo venoso, durante o período em que foi realizada e um ano após a etapa anterior. Para fins estatísticos, os pacientes foram divididos em alto risco e baixo risco, e estratificados quanto a erro na quimioprofilaxia em: precisavam, mas não fizeram profilaxia; não precisavam, mas fizeram profilaxia; fizeram profilaxia não padronizada; e não podiam, mas fizeram profilaxia. Resultados Foram avaliados 399 pacientes internados, sendo 56 pacientes antes do início do programa de conscientização, 255 durante o programa e 88 após um ano. Antes da realização da semana de conscientização, apenas 35,7% dos pacientes estavam recebendo a quimioprofilaxia adequada; após a semana de conscientização, houve um aumento do número de prescrições corretas, que passou para 63,9% (p < 0,001). Após um ano sem as aulas de conscientização, a manutenção da quimioprofilaxia não foi tão eficaz, com uma tendência ao aumento do número de profilaxias incorretas (p = 0,081). Conclusão A quimioprofilaxia é utilizada em uma porcentagem muito pequena nos pacientes internados, sendo necessários programas de esclarecimento de sua importância na prevenção do tromboembolismo venoso e a realização de monitoramento contínuo para auxiliar na sua prescrição.

Abstract Background Complications of venous thromboembolism are common among both medical and surgical hospital patients. Objective To identify what, if any, pharmacological prophylaxis for venous thromboembolism was given to cancer patients in hospital before and after implementation of a program to raise awareness of its importance. Methods This was a cross-sectional study conducted in three phases at distinct times: before a program to raise awareness of the importance of prophylaxis against venous thromboembolism was implemented, during years when the program was being run, and 1 year after the end of the program. For statistical analysis, patients were classified as high risk or no risk and categorized on the basis of erroneous pharmacological prophylaxis, as follows: “needed prophylaxis, but were not given it”; “did not need prophylaxis, but were given it”; “were given nonstandard prophylaxis”; or “should not have been given prophylaxis, but were given it”. Results A total of 399 hospital patients were assessed: 56 before the awareness-raising program, 255 during the program and 88 1 year after the program was last run. Before any awareness-raising weeks, just 35.7% of the patients were being given the correct pharmacological prophylaxis; after awareness-raising weeks, the proportion of correct prescriptions increased to 63.9% (p < 0.001). After one year with no awareness-raising efforts, maintenance of pharmacological prophylaxis was no longer as effective, and there was a trend for the proportion of incorrect prophylaxis to increase (p = 0.081). Conclusions Pharmacological prophylaxis is given to a very small percentage of patients in hospital and programs are needed to raise awareness of its importance in the prevention of venous thromboembolism and continuous monitoring is needed to facilitate prescriptions.

Persistent below-knee great saphenous vein reflux after above-knee endovenous laser ablation with 1470-nm laser: a prospective study / Persistência do refluxo da veia safena magna na perna após termoablação com laser 1470 nm na coxa: estudo prospectivo

BACKGROUND: In endovenous laser ablation (EVLA), the great saphenous vein (GSV) is usually ablated from the knee to the groin, with no treatment of the below-knee segment regardless of its reflux status. However, persistent below-knee GSV reflux appears to be responsible for residual varicosities and symptoms of venous disease. OBJECTIVES: To evaluate clinical and duplex ultrasound (DUS) outcomes of the below-knee segment of the GSV after above-knee EVLA associated with conventional surgical treatment of varicosities and incompetent perforating veins. METHODS: Thirty-six patients (59 GSVs) were distributed into 2 groups, a control group (26 GSVs with normal below-knee flow on DUS) and a test group (33 GSVs with below-knee reflux). Above-knee EVLA was performed with a 1470-nm bare-fiber diode laser and supplemented with phlebectomies of varicose tributaries and insufficient perforating-communicating veins through mini-incisions. Follow-up DUS, clinical evaluation using the venous clinical severity score (VCSS), and evaluation of complications were performed at 3-5 days after the procedure and at 1, 6, and 12 months. RESULTS: Mean patient age was 45 years, and 31 patients were women (86.12%). VCSS improved in both groups. Most patients in the test group exhibited normalization of reflux, with normal flow at the beginning of follow-up (88.33% of GSVs at 3-5 days and 70% at 1 month). However, in many of these patients reflux eventually returned (56.67% of GSVs at 6 months and 70% at 1 year). CONCLUSIONS: These data suggest that reflux in the below-knee segment of the GSV was not influenced by the treatment performed.

CONTEXTO: A termoablação da veia safena magna com laser (em inglês, endovenous laser therapy - EVLA) geralmente é realizada do joelho até a virilha, sem tratamento do segmento abaixo do joelho, independentemente do seu status de refluxo. Entretanto, a persistência de refluxo da veia safena magna (VS.M) na perna parece ser responsável por varizes residuais e sintomas da doença venosa. OBJETIVOS: Avaliar a evolução clínica e os resultados do eco-Doppler da VS.M na perna após EVLA na coxa associada ao tratamento cirúrgico convencional de varizes e veias perfurantes incompetentes. Métodos Trinta e seis pacientes (59 VS.Ms) foram divididos em dois grupos: grupo-controle (26 VS.Ms com fluxo normal na perna ao eco-Doppler) e grupo-teste (33 VS.Ms com refluxo na perna). EVLA na coxa foi realizada com laser 1470 nm com fibra nua, associada a flebectomia das veias tributárias e perfurantes-comunicantes insuficientes através de mini-incisões. Acompanhamento com eco-Doppler, avaliação clínica pelo escore de gravidade clínica venosa (em inglês, venous clinical severity score – VCSS) e avaliação das complicações foram realizados 3-5 dias após o procedimento e em 1, 6 e 12 meses. RESULTADOS: A idade média dos pacientes era de 45 anos, e 31 eram mulheres (86,12%). Os dois grupos apresentaram melhora no VCSS. A maioria do grupo-teste apresentou normalização do refluxo, com fluxo normal no início do acompanhamento (88,33% das VS.Ms em 3-5 dias e 70% em 1 mês). Porém, esses pacientes evoluíram com retorno do refluxo (56,67% das VS.Ms em 6 meses e 70% em 1 ano). CONCLUSÕES: Esses dados sugerem que o refluxo da VS.M na perna não foi influenciado pelo tratamento realizado.

Trombose induzida pelo calor endovenoso: relato de dois casos tratados com rivaroxabana e revisão da literatura / Endothermal heat-induced thrombosis (EHIT): reports on two case treated with rivaroxaban and literature review

Define-se trombose induzida pelo calor endovenoso como a propagação do trombo a partir de uma veia superficial em direção a uma veia mais profunda. Em geral, é considerada clinicamente insignificante quando não há propagação do trombo para o sistema venoso profundo. Essa condição pode ser tratada com terapia anticoagulante, embora a observação pareça ser suficiente, principalmente para graus menores. Neste estudo, relatamos dois casos de trombose induzida pelo calor endovenoso que teriam indicação de heparina de baixo peso molecular até a resolução do quadro. Porém, optou-se pelo uso da rivaroxabana (15 mg de 12 em 12h), com resolução completa do trombo em 4 semanas (caso 1) e em 7 dias (caso 2). A rivaroxabana pode ser uma alternativa promissora no tratamento da trombose induzida pelo calor endovenoso avançada, pela simplicidade da posologia, sem comprometimento da eficácia ou da segurança. São necessários estudos prospectivos, randomizados e controlados que possibilitem melhor entendimento da condição e o desenvolvimento de recomendações mais definitivas sobre opções de prevenção e tratamento.

Endothermal heat-induced thrombosis (EHIT) is defined as propagation of a thrombus from a superficial vein into a deeper vein and is generally considered clinically insignificant if the thrombus does not propagate to the deep venous system. The condition can be treated with anticoagulation therapy, although monitoring may be sufficient, especially in less severe cases. In this paper we report on two cases of EHIT that met the criteria for indication of low molecular weight heparin until resolution of symptoms. However, the treatment actually chosen was 15 mg of rivaroxaban every 12 h and the outcomes were complete thrombus resolution in 4 weeks in Case 1 and 7 days in Case 2. Rivaroxaban may be a promising alternative for treatment of severe EHIT because the dosage regimen is simplified without compromising efficacy or safety. Prospective, randomized, controlled studies are needed to better understand EHIT and to develop more definitive recommendations on prevention and treatment options for this condition.

Veia cava superior esquerda persistente: relato de caso / Persistent left superior vena cava: case report

O pleno conhecimento da anatomia vascular torácica é de suma importância para os profissionais envolvidos na realização de procedimentos invasivos como a punção de acesso venoso central. A persistência da veia cava superior esquerda é a malformação venosa torácica mais frequente, e seu diagnóstico costuma ser incidental. Apresentamos o caso de uma paciente de 14 anos em que o diagnóstico de veia cava superior esquerda persistente foi incidental em exame de imagem de controle após colocação de cateter venoso totalmente implantável. A paciente não apresentou dificuldade de infusão de quimioterapia pelo cateter e não houve complicações relacionadas ao cateter.

It is extremely important that health professionals involved in invasive procedures such as central venous access have a thorough knowledge of thoracic vascular anatomy. Persistent left superior vena cava is the most common congenital thoracic venous abnormality and is generally diagnosed as an incidental finding. We present the case of a 14-year-old female patient in whom a persistent left superior vena cava was diagnosed as an incidental finding of a control imaging exam after placement of a totally implantable venous catheter. The patient did not exhibit any difficulties with infusion of chemotherapy via the catheter and there were no complications related to the catheter.

Development of an ex vivo model of endovenous laser ablation of the great saphenous vein in a pilot study.

PURPOSE: To develop an ex vivo model for the analysis of macroscopic, histological and immunohistochemical changes after experimental endovenous laser ablation (EVLA) of the great saphenous vein (GSV). METHODS: We describe a model produced with glass tubes and introducer sheaths to mimic the physiological conditions of EVLA procedures, such as tumescence and blood flow. A pilot study was conducted to evaluate an ex vivo procedure of EVLA of an incompetent GSV segment using a 1470-nm radial fiber diode laser (7 W power) and an automatic pull-back device. The vein segment was analyzed macroscopically and by hematoxylin & eosin staining, elastic fiber histochemistry, Gomori's trichrome staining, and alpha-smooth muscle actin immunohistochemistry. RESULTS: No perforations were observed macroscopically. No muscle cell adhesion was observed in the central part of the ablated vein, showing tissue disruption. There was low labeling for elastic fibers, disruption of muscle fibers, and a reduced expression of the specific marker for this cell type. CONCLUSION: This ex vivo endovenous laser ablation model is a low cost alternative to in vivo experiments, providing standardized experimental conditions.