Association between platelet lymphocyte ratio and neutrophil lymphocyte ratio and clinical outcomes following carotid endarterectomy.

Background: Approximately 30% of stroke cases result from carotid disease. Although several risk factors for complications after carotid endarterectomy have been identified, the existence of a biomarker that can estimate postoperative risk in these patients has not yet been proven. Objectives: This study aimed to investigate correlations between the platelet-lymphocyte ratio (PLR) and the neutrophil-lymphocyte ratio (NLR) and postoperative clinical outcomes in patients undergoing carotid endarterectomy. Methods: A retrospective study was conducted, including 374 patients who underwent carotid endarterectomy between 2002 and 2019 due to moderate to high extracranial internal carotid artery stenosis. Their platelet-lymphocyte ratio and neutrophil-lymphocyte ratios were obtained from the same blood samples. Results: There was a statistically significant correlation between the PLR and the occurrence of restenosis (p < 0.01) and acute myocardial infarction (AMI) after endarterectomy (p = 0.03). Additionally, there was a statistically significant correlation between the PLR and the combined outcomes stroke and/or AMI and/or death (p = 0.03) and stroke and/or AMI and/or death and/or restenosis (p < 0.01). However, there were no significant correlations between NLR and these outcomes (p = 0.05, p = 0.16). Conclusions: The platelet-lymphocyte ratio proved to be a useful test for predicting occurrence of strokes, acute myocardial infarctions, and deaths during the postoperative period after carotid endarterectomy. It was also associated with the risk of postoperative restenosis.

Contexto: Aproximadamente 30% dos casos de acidente vascular cerebral (AVC) resultam de doença carotídea. Embora vários fatores de risco para complicações pós-endarterectomia carotídea tenham sido identificados, ainda não foi comprovada a existência de um biomarcador que possa estimar o risco pós-operatório nesses pacientes. Objetivos: Correlacionar o índice plaqueta-linfócito (IPL) e o índice neutrófilo-linfócito (INL) com os desfechos clínicos pós-operatórios em pacientes submetidos a endarterectomia carotídea. Métodos: Estudo retrospectivo que incluiu 374 pacientes submetidos a endarterectomia carotídea, entre 2009 e 2019, por estenose extracraniana da artéria carótida interna. O IPL e o INL foram calculados, tendo sido obtidos das mesmas amostras de sangue. Resultados: Houve correlação estatisticamente significativa entre IPL e presença de reestenose (p<0,01) e infarto agudo do miocárdio (IAM) após endarterectomia (p=0,03). Os desfechos combinados AVC e/ou IAM e/ou óbito e AVC e/ou IAM e/ou óbito e/ou reestenose apresentaram, respectivamente, correlação estatisticamente significativa com o IPL (p=0,03; p<0,01) e não significativa com o INL (p=0,05; p=0,16). Conclusões: O IPL mostrou-se um teste útil, capaz de predizer os desfechos de AVC e/ou IAM e/ou óbito em pacientes no pós-operatório de endarterectomia carotídea, relacionando-se também com risco de reestenose pós-operatória.

Association between platelet lymphocyte ratio and neutrophil lymphocyte ratio and clinical outcomes following carotid endarterectomy / Associação do índice plaqueta-linfócito e do índice neutrófilo-linfócito com desfechos clínicos após endarterectomia de carótida

Abstract Background Approximately 30% of stroke cases result from carotid disease. Although several risk factors for complications after carotid endarterectomy have been identified, the existence of a biomarker that can estimate postoperative risk in these patients has not yet been proven. Objectives This study aimed to investigate correlations between the platelet-lymphocyte ratio (PLR) and the neutrophil-lymphocyte ratio (NLR) and postoperative clinical outcomes in patients undergoing carotid endarterectomy. Methods A retrospective study was conducted, including 374 patients who underwent carotid endarterectomy between 2002 and 2019 due to moderate to high extracranial internal carotid artery stenosis. Their platelet-lymphocyte ratio and neutrophil-lymphocyte ratios were obtained from the same blood samples. Results There was a statistically significant correlation between the PLR and the occurrence of restenosis (p < 0.01) and acute myocardial infarction (AMI) after endarterectomy (p = 0.03). Additionally, there was a statistically significant correlation between the PLR and the combined outcomes stroke and/or AMI and/or death (p = 0.03) and stroke and/or AMI and/or death and/or restenosis (p < 0.01). However, there were no significant correlations between NLR and these outcomes (p = 0.05, p = 0.16). Conclusions The platelet-lymphocyte ratio proved to be a useful test for predicting occurrence of strokes, acute myocardial infarctions, and deaths during the postoperative period after carotid endarterectomy. It was also associated with the risk of postoperative restenosis.

Resumo Contexto Aproximadamente 30% dos casos de acidente vascular cerebral (AVC) resultam de doença carotídea. Embora vários fatores de risco para complicações pós-endarterectomia carotídea tenham sido identificados, ainda não foi comprovada a existência de um biomarcador que possa estimar o risco pós-operatório nesses pacientes. Objetivos Correlacionar o índice plaqueta-linfócito (IPL) e o índice neutrófilo-linfócito (INL) com os desfechos clínicos pós-operatórios em pacientes submetidos a endarterectomia carotídea. Métodos Estudo retrospectivo que incluiu 374 pacientes submetidos a endarterectomia carotídea, entre 2009 e 2019, por estenose extracraniana da artéria carótida interna. O IPL e o INL foram calculados, tendo sido obtidos das mesmas amostras de sangue. Resultados Houve correlação estatisticamente significativa entre IPL e presença de reestenose (p<0,01) e infarto agudo do miocárdio (IAM) após endarterectomia (p=0,03). Os desfechos combinados AVC e/ou IAM e/ou óbito e AVC e/ou IAM e/ou óbito e/ou reestenose apresentaram, respectivamente, correlação estatisticamente significativa com o IPL (p=0,03; p<0,01) e não significativa com o INL (p=0,05; p=0,16). Conclusões O IPL mostrou-se um teste útil, capaz de predizer os desfechos de AVC e/ou IAM e/ou óbito em pacientes no pós-operatório de endarterectomia carotídea, relacionando-se também com risco de reestenose pós-operatória.

Carotid Plaque Composition and the Importance of Non-Invasive in Imaging Stroke Prevention.

Luminal stenosis has been the standard feature for the current management strategies in patients with atherosclerotic carotid disease. Histological and imaging studies show considerable differences between plaques with identical degrees of stenosis. They indicate that specific plaque characteristics like Intraplaque hemorrhage, Lipid Rich Necrotic Core, Plaque Inflammation, Thickness and Ulceration are responsible for the increased risk of ischemic events. Intraplaque hemorrhage is defined by the accumulation of blood components within the plaque, Lipid Rich Necrotic Core is composed of macrophages loaded with lipid, Plaque Inflammation is defined as the process of atherosclerosis itself and Plaque thickness and Ulceration are defined as morphological features. Advances in imaging methods like Magnetic Resonance Imaging, Ultrasound, Computed Tomography and Positron Emission Tomography have enabled a more detailed characterization of the plaque, and its vulnerability is linked to these characteristics, changing the management of these patients based only on the degree of plaque stenosis. Studies like Rotterdam, ARIC, PARISK, CAPIAS and BIOVASC were essential to evaluate and prove the relevance of these characteristics with cerebrovascular symptoms. A better approach for the prevention of stroke is needed. This review summarizes the more frequent carotid plaque features and the available validation from recent studies with the latest evidence.

Short-Term Outcomes of Transfemoral Carotid Artery Stenting and Carotid Endarterectomy in Symptomatic Patients: Data from a Multicentric Prospective Registry in Brazil.

BACKGROUND: Transfemoral carotid artery stenting (TF-CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. Because their main objective is to prevent future ischemic events, regular reassessment of the outcomes is mandatory for providing the best therapy. The purpose of this study was to describe the practice and the outcomes of TF-CAS and CEA in symptomatic patients in public university hospitals in Brazil, using data from a prospective multicentric registry. METHODS: A prospective 8-year observational study of patients with symptomatic carotid artery atherosclerotic disease that underwent TF-CAS and CEA in 5 public university hospitals affiliated with the RHEUNI (Registry Project of Vascular Disease in the Public University Hospitals of São Paulo). All consecutive procedures were included. The indications for the procedures were determined by each surgeon's individual discretion, in accordance with a preoperative risk evaluation. The outcome measures were any 30-day follow-up death, stroke, myocardial infarction (MI), and their combined outcome (major adverse cardiovascular events [MACE]). The registration of the study was made at clinicaltrials.gov NCT02538276. RESULTS: From January 2012 through December 2019, 376 consecutive and symptomatic patients were included in the study records. There were 152 TF-CAS procedures (40.4%) and 224 CEA procedures (59.5%). All completed the 30-day follow-up period. Occurrence of death (TF-CAS: 0.66% × CEA: 0.66%, P = 0.99), stroke (TF-CAS: 4.61% × CEA: 4.46%, P = 0.99), and MI (TF-CAS: 0.66% × CEA: 0%, P = 0.403) were similar in both groups, without statistically significant differences. MACE rate did not differ in both groups (TF-CAS: 5.92% × CEA: 4.46%, P = 0.633). CONCLUSIONS: Data from a prospective registry of 5 Brazilian university hospitals showed that TF-CAS and CEA in symptomatic patients had similar 30-day perioperative rates of death, stroke, and MI and their combination.

Guidelines for superficial venous thrombosis.

Superficial venous thrombosis (SVT) or superficial thrombophlebitis is characterized by thrombi within superficial veins, with partial involvement or occlusion of the lumen and inflammatory reaction along the course of the vein. Clinical diagnosis tends to be straightforward, but supplementary tests and examinations are needed to confirm thrombosis extension and possible thromboembolic complications. SVT can be associated with deep venous thrombosis in 6 to 40% of cases, with asymptomatic pulmonary embolism (PE) in 20 to 33%, and with symptomatic PE in 2 to 13%. Despite the morbidity and complications, there are currently no Brazilian guidelines for SVT. These guidelines cover the most important issues related to SVT definition, terminology, and etiology, and set out recommendations for diagnosis and treatment.

Thoracic aortic aneurysm in a patient with tuberous sclerosis.

Tuberous sclerosis is a genetic disease with autosomal dominant transmission. Its classic presentation comprises epilepsy, mental deficiencies, and sebaceous adenomas. Aneurysms of the aorta can be detected in people with tuberous sclerosis ranging from children a few months old to young adults. We report the case of a young patient diagnosed with a saccular thoracic aortic aneurysm and tuberous sclerosis who was successfully treated using an endovascular approach.

Primary stenting for femoropopliteal peripheral arterial disease: analysis up to 24 months.

BACKGROUND: Primary stenting is a well-established treatment option for femoropopliteal arterial obstructive disease. There is a shortage of Brazilian studies of the subject. OBJECTIVES: To evaluate short and mid-term clinical and radiological outcomes in patients classified as Rutherford 3-6 and treated with stenting of femoropopliteal lesions. METHODS: Analysis based on a prospectively populated database of patients treated from July 2012 to July 2015. The primary endpoint was primary patency. Secondary endpoints were clinical and ankle/brachial index changes. Target Vessel Revascularization, limb salvage rate and death, within a 24-month follow-up period. RESULTS: 64 patients were enrolled, including 61 TASC II A / B lesions (95%). The primary patency rates at 6, 12, and 24 months were 95.2%, 79.1% and 57.9%, respectively. Cox regression analysis revealed lower patency rates in patients with occlusive disease (hazard ratio [HR], 6.64; 95% confidence interval [CI], 1.52-28,99, p = 0.02), as well as patency loss about 6 times higher in TASC B than in TASC A patients ([HR], 5.95, 95% CI, 1.67-21.3, p = 0.0061). At 12 months, 90.38% of the patients remained asymptomatic. The limb salvage rate at 24 months was 94.3% (95% CI, 87.9-100%). Freedom from TVR at 24 months was 90.5% (95% CI 82.8-98.9%). CONCLUSIONS: Results of primary patency were compatible with international studies, despite the more advanced stage of the vascular disease observed in our group. Occlusive disease and complex lesions were both associated with worse outcomes.

Aneurisma de aorta torácica em paciente com esclerose tuberosa / Thoracic aortic aneurysm in a patient with tuberous sclerosis

A esclerose tuberosa é uma doença genética de transmissão autossômica dominante. Caracteriza-se, na sua apresentação clássica, por epilepsia, deficiência mental e adenomas sebáceos. Aneurismas de aorta podem acometer desde crianças com poucos meses de vida até adultos jovens portadores de esclerose tuberosa. Apresentamos o caso de uma paciente jovem com diagnóstico de aneurisma sacular de aorta torácica e esclerose tuberosa tratada com sucesso por via endovascular

Tuberous sclerosis is a genetic disease with autosomal dominant transmission. Its classic presentation comprises epilepsy, mental deficiencies, and sebaceous adenomas. Aneurysms of the aorta can be detected in people with tuberous sclerosis ranging from children a few months old to young adults. We report the case of a young patient diagnosed with a saccular thoracic aortic aneurysm and tuberous sclerosis who was successfully treated using an endovascular approach

Tratamento da doença arterial obstrutiva periférica em território femoropoplíteo com stent primário: análise em até 24 meses / Primary stenting for femoropopliteal peripheral arterial disease: analysis up to 24 months

O stent primário é uma opção de tratamento bem estabelecida para a doença arterial periférica em território femoropoplíteo. Estudos nacionais são escassos. Objetivos Avaliar desfechos clínicos e radiológicos em curto e médio prazo em pacientes classificados como Rutherford 3-6, tratados com o uso de stent em lesões femoropoplíteas. Métodos A análise foi realizada com base em um banco de dados prospectivamente mantido de doentes tratados entre julho de 2012 e julho de 2015. O objetivo primário foi a perviedade. Os objetivos secundários foram melhora na classificação de Rutherford, índice tornozelo/braço, revascularização do vaso-alvo, taxa de salvamento do membro e óbito em até 24 meses. Resultados Foram incluídos 64 pacientes, sendo 61 com lesões TASC II A/B (95%). A taxa de perviedade primária em 6, 12 e 24 meses foi de 95,2%, 79,1% e 57,9%, respectivamente. A análise de regressão de Cox revelou uma menor perviedade em pacientes com doença oclusiva (RR, 6,64, IC 95%, 1,52-28,99, p = 0,02), bem como uma perda de perviedade cerca de seis vezes maior em doentes TASC B do que TASC A (RR, 5,95, IC 95%, 1,67-21,3, p = 0,0061). Em 12 meses, 90,38% dos doentes permaneceram assintomáticos. A taxa de salvamento do membro em 24 meses foi de 94,3% (IC 95%, 87,9-100%). A ausência de revascularização do vaso-alvo em 24 meses foi de 90,5% (IC 95%, 82,8-98,9%). Conclusões Os resultados foram compatíveis com estudos internacionais, apesar do estágio mais avançado da doença vascular observada em nosso grupo. Piores desfechos foram associados a doença oclusiva e lesões complexas

Primary stenting is a well-established treatment option for femoropopliteal arterial obstructive disease. There is a shortage of Brazilian studies of the subject. Objectives To evaluate short and mid-term clinical and radiological outcomes in patients classified as Rutherford 3-6 and treated with stenting of femoropopliteal lesions. Methods Analysis based on a prospectively populated database of patients treated from July 2012 to July 2015. The primary endpoint was primary patency. Secondary endpoints were clinical and ankle/brachial index changes. Target Vessel Revascularization, limb salvage rate and death, within a 24-month follow-up period. Results 64 patients were enrolled, including 61 TASC II A / B lesions (95%). The primary patency rates at 6, 12, and 24 months were 95.2%, 79.1% and 57.9%, respectively. Cox regression analysis revealed lower patency rates in patients with occlusive disease (hazard ratio [HR], 6.64; 95% confidence interval [CI], 1.52-28,99, p = 0.02), as well as patency loss about 6 times higher in TASC B than in TASC A patients ([HR], 5.95, 95% CI, 1.67-21.3, p = 0.0061). At 12 months, 90.38% of the patients remained asymptomatic. The limb salvage rate at 24 months was 94.3% (95% CI, 87.9-100%). Freedom from TVR at 24 months was 90.5% (95% CI 82.8-98.9%). Conclusions Results of primary patency were compatible with international studies, despite the more advanced stage of the vascular disease observed in our group. Occlusive disease and complex lesions were both associated with worse outcomes

Percutaneous retrograde crossing of a near-occluded celiac trunk via the superior mesenteric artery as an adjuvant maneuver for antegrade stenting / Passagem retrógrada percutânea de uma lesão estenosante crítica do tronco celíaco via artéria mesentérica superior como manobra adjuvante na abordagem anterógrada

We describe the case of a 63-year-old woman with chronic mesenteric ischemia, persistent postprandial upper abdominal pain and progressive weight loss. Retrograde recanalization was performed via the superior mesenteric artery in order to achieve the goal of crossing the near-occlusion, showing that retrograde catheterization of the celiac trunk can be a feasible approach in challenging cases in which an antegrade approach fails as a single maneuver.

Descrevemos o caso de uma mulher de 63 anos de idade, com isquemia mesentérica crônica, dor abdominal pós-prandial e emagrecimento progressivo. A recanalização retrógrada foi realizada através da artéria mesentérica superior para transpassar a estenose crítica. Demonstra-se assim que o cateterismo retrógrado do tronco celíaco pode ser uma abordagem viável em casos difíceis, em que a abordagem anterógrada falha como manobra única.

Aneurisma de aorta abdominal infectado por Salmonella species / Infected abdominal aneurysm due to Salmonella species

Os aneurismas de aorta abdominal infecciosos (AAAIs) são raros e apresentam uma alta mortalidade devido à septicemia e ao risco de ruptura. A opção terapêutica consagrada consiste na correção aberta com ressecção do aneurisma, debridamento e reconstrução com veia autóloga. Mais recentemente, alguns grupos vêm relatando séries de casos nas quais se realizou tratamento endovascular. Em ambas as opções, a antibioticoterapia adjuvante é imperativa. Relatamos um caso ilustrativo em que o tratamento de escolha foi a cirurgia aberta com reconstrução utilizando-se veia autóloga.

Infected abdominal aortic aneurysms are rare and have high mortality due to sepsis and the possibility of rupture. The treatment of choice is open repair with aneurysm resection, debridement and reconstruction with an autologous vein graft. More recently, case series have been described in which the endovascular approach was the first option. With both approaches adjuvant antibiotic therapy is imperative. We report an illustrative case in which the treatment was open surgery reconstruction using an autologous vein graft.