Geographical disparities in access to surgical treatment and mortality rates from abdominal aortic aneurysms in Brazil: A retrospective longitudinal study.

INTRODUCTION: Abdominal aortic aneurysm (AAA) is a growing public health problem, and not all patients have access to surgery when needed. This study aimed to analyze spatiotemporal variations in AAA mortality and surgical procedures in Brazilian intermediate geographic regions and explore the impact of different surgical techniques on operative mortality. METHODS: A retrospective longitudinal study was conducted to evaluate AAA mortality from 2008 to 2020 using space-time cube (STC) analysis and the emerging hot spot analysis tool through the Getis-Ord Gi* method. RESULTS: There were 34,255 deaths due to AAA, 13,075 surgeries to repair AAA, and a surgical mortality of 14.92%. STC analysis revealed an increase in AAA mortality rates (trend statistic = +1.7693, p = 0.0769) and a significant reduction in AAA surgery rates (trend statistic = -3.8436, p = 0.0001). Analysis of emerging hotspots revealed high AAA mortality rates in the South, Southeast, and Central-West, with a reduction in procedures in São Paulo and Minas Gerais States (Southeast). In the Northeast, there were extensive areas of increasing mortality rates and decreasing procedure rates (cold spots). CONCLUSION: AAA mortality increased in several regions of the country while surgery rates decreased, demonstrating the need for implementing public health policies to increase the availability of surgical procedures, particularly in less developed regions with limited access to services.

Influence of compression therapy following varicose vein surgery: a prospective randomized study.

Background: The use of compression dressings after phlebectomy is based solely on clinical experience due to the lack of a unified set of definitive recommendations, which makes clinical practice extremely heterogeneous. Objectives: To evaluate compression therapy with elastic stockings for 7 days after phlebectomy. Methods: We randomly allocated 104 lower limbs with disease classified as C1 and C2 to 1 of 2 groups: an intervention group (64 limbs) - wearing elastic compression stockings for the first 7 days after phlebectomy; or a control group (40 limbs) - given conventional bandaging for 24 hours postoperatively. We compared clinical response by analyzing the evolution of symptoms, hematoma formation, and preoperative vs. postoperative limb volume. Results: Pain (median 1.0 vs. 1.5, p=0.0320) and limb volume (mean 43.7 vs. 99.8, p=0.0071) were significantly improved in patients wearing elastic compression stockings for 7 days after phlebectomy compared with controls. Conclusions: Use of elastic compression therapy for 7 days after phlebectomy was effective for improving pain and lower limb volume.

Contexto: O uso de curativos após flebectomia é baseado apenas na experiência clínica, visto que não existe um conjunto unificado de recomendações definitivas, o que torna a prática clínica extremamente variável. Objetivos: Avaliar o uso de terapia elástica compressiva por 7 dias após flebectomia. Métodos: Cento e quatro membros inferiores, classificados como CEAP C1 e C2, foram randomizados em dois grupos: grupo de intervenção (64 membros) ­ uso de meia elástica por 24 horas após a cirurgia ­ e grupo controle (40 membros) ­ uso de curativo convencional por 7 dias após a cirurgia. A resposta clínica foi comparada por meio de análise da evolução dos sintomas, de hematoma e do volume dos membros antes e depois da cirurgia. Resultados: Os pacientes submetidos a terapia compressiva elástica apresentaram melhora significativa na dor (mediana 1,0 vs. 1,5; p=0,0320) e no volume dos membros (média 43,7 vs. 99,8; p=0,0071) em comparação ao grupo controle. Conclusões: O emprego da terapia compressiva elástica por 7 dias após flebectomia mostrou-se efetivo na melhora da dor e do volume dos membros inferiores.

Prevalence of rare visceral aneurysms on 92,833 CAT scans (2005-2021).

Background: Studies on the prevalence of rare visceral aneurysms are still scarce and the few studies that have focused on these aneurysms present prevalence rates in groups of patients with visceral aneurysms, but little is known about their prevalence in the general population. Objectives: To assess the prevalence of rare visceral aneurysms on CAT scans performed for diagnosis and follow-up of patients with other vascular pathologies. Methods: This cross-sectional study began by accessing all reports from CAT scans performed between January 2005 and July 2021 at a private hospital of excellence located in the city of São Paulo. A software program for pre-indexed reports was used to search the Radiological Information System (RIS) database to identify reports of patients with intra-abdominal aneurysms. Results: CAT scan reports from 92,883 patients were accessed. Of these, 2,597 (2.795%) showed intra-abdominal aneurysms, 937 (1.063%) of which were visceral, including 158 (0.171%) rare visceral aneurysms, which were more frequent among male patients and in the following segments: celiac trunk (0.098%), superior mesenteric (0.033%), left gastric (0.010%), pancreatic-duodenal (0.009%), and gastroduodenal arteries (0.005%) and the pancreatic arch (0.004%). Lower prevalence was found in other segments. Additional findings revealed concomitance of rare visceral aneurysms with other intra-abdominal aneurysms ranging from 11.11% to 66.67%. Conclusions: The prevalence of rare visceral aneurysms in a large population undergoing CAT scan was 0.171%, with greater involvement in male patients.

Patterns of flow drainage from varicose veins originating in the incompetent great saphenous vein.

Background: Chronic venous insufficiency affects the lives of many people and therefore constitutes a public health problem. Knowledge of the drainage patterns of reflux from varicose veins secondary to incompetent saphenous veins is essential to define the best therapeutic management. Objectives: To determine the reflux drainage patterns from varicose veins originating in incompetent GSV, the prevalence of perforating veins (PV), and their relationships with symptoms. Methods: 55 ultrasound reports were analyzed to determine the drainage patterns of reflux from the GSV, location and diameter of PV drainage, and staging of symptoms. Results: In 64% of the sample, reflux from varicose veins drained to PVs, in 4% reflux drained to the GSV itself, in another 4% drainage was to the small saphenous vein, and in 29% drainage was to varicose trunk veins in which no direct communication with the deep system could be identified. No associations were observed between symptoms and reflux drainage patterns or PV diameters. Conclusions: For this sample, PVs were responsible for draining flow from varicose veins in 64% of cases. Neither PV diameters nor GSV reflux patterns were associated with severity of symptoms.

Introdução: A insuficiência venosa crônica impacta a vida de muitas pessoas, constituindo-se, assim, como um problema de saúde pública. Conhecer o padrão de drenagem do refluxo das varizes associadas à veia safena incompetente é fundamental para definir a melhor programação terapêutica. Objetivos: Determinar os padrões de drenagem do refluxo de varizes originadas da veia safena magna incompetente, a prevalência de veias perfurantes e a relação com os sintomas. Métodos: Foram analisados 55 registros ultrassonográficos de pacientes com refluxo da veia safena magna para determinar padrões de drenagem do refluxo dessa veia, pontos de refluxo das varizes, localização e diâmetro das perfurantes de drenagem e graduação dos sintomas. Resultados: O principal padrão de refluxo encontrado foi originado da junção safenofemoral com comprometimento proximal da veia safena magna. Em 64% dos pacientes, o refluxo das varizes drenou para veias perfurantes - 4% drenavam para a própria veia safena magna; em outros 4%, a drenagem era para a veia safena parva; e, em 29%, a drenavam destinava-se para varizes tronculares em que não se identificou comunicação direta com o sistema venoso profundo. Não foi observada associação dos sintomas com os padrões de drenagem do refluxo ou diâmetro das perfurantes. Conclusão: Para essa amostra, as veias perfurantes foram responsáveis pelo escoamento do fluxo oriundo das varizes em 64% dos casos. O diâmetro das veias perfurantes e o padrão de refluxo da veia safena não estiveram associados à gravidade dos sintomas.

Improvement of semen parameters after coil embolization of varicoceles: a systematic review.

This systematic review was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, including clinical studies in which one of the outcomes was semen parameter improvement after varicocele embolization using coils only. The objective of the review was to assess the evidence on the role of embolization using coils alone for semen parameter improvement in men with varicocele, since embolization using coils is the most cost-effective method of varicocele repair. Study quality was assessed using the methodological index for non-randomized studies (MINORS). Out of six retrospective and two prospective observational or comparative clinical studies involving 701 patients, semen concentration improved significantly in all five studies that assessed this parameter. Mean semen motility improved significantly in seven studies. The impact of embolization on semen density could not be analyzed.

Trata-se de uma revisão sistemática conduzida de acordo com o PRISMA 2009 (Principais Itens para Relatar Revisões Sistemáticas e Metanálises) que incluiu estudos em que a melhora dos parâmetros seminais tenha sido um dos desfechos. Esta revisão foi realizada com o objetivo de avaliar as evidências sobre o papel da embolização com uso apenas de molas na melhora de parâmetros seminais em homens com varicocele, uma vez que a embolização apenas com molas é o método com melhor custo-benefício para o reparo de varicoceles. A qualidade dos estudos foi analisada com o índice MINORS. Em seis estudos clínicos retrospectivos e em outros dois prospectivos observacionais ou comparativos, a concentração seminal melhorou significativamente em todos os cinco estudos que avaliaram esse parâmetro. A motilidade seminal melhorou significativamente em sete estudos. Não foi possível analisar o impacto da embolização com molas na densidade seminal.

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.

Percutaneous endovascular delivery of calcium chloride to the intact porcine carotid artery: A novel animal model of arterial calcification.

OBJECTIVE: The present study evaluated the effect of endovascular administration of calcium chloride to the carotid artery of swines, to create a model of arterial calcification. METHODS: Fifteen Large White pigs were used for the study. Via endovascular treatment, carotid arteries were exposed during 9 min to either calcium chloride (experimental artery) or saline (control artery) with the use of the TAPAS catheter. Intravascular ultrasound (IVUS) imaging was obtained at baseline, postprocedure and at 30 days. Optical coherence tomography (OCT) imaging was obtained in vitro after carotids were harvested. Longitudinally cut parallel arterial segments were placed in a system of delicate clamps and underwent uniaxial strain test. All arteries underwent histopathological examination. RESULTS: Calcium chloride treated segments showed extensive circumferential parietal calcification evident on both IVUS and OCT. Reduction in minimal lumen area on IVUS was evident in experimental arteries both at 24 hr and 30 days postprocedure. Histopathologic assessment (Von Kossa stain) confirmed medial calcification with mild intimal thickening. Biomechanical testing showed treated segments to have smaller breaking strength and less elastic deformation than controls. CONCLUSION: We developed a nonexpensive, reproducible model of early carotid medial calcification in pigs. Our model has the potential to help the development of research to unravel mechanisms underlying arterial calcification, the use of current or new devices to treat calcified lesions as well as to serve as an option for training interventionalists on the use of such devices.

Impact of Cooling on Lowering the Pain Threshold in Patients Undergoing Sclerotherapy.

BACKGROUND: Liquid sclerotherapy is the treatment of choice for telangiectasias. However, pain caused by the procedure is a barrier to treatment adherence by patients. OBJECTIVE: To evaluate the use of skin cooling for the management of pain in patients undergoing liquid sclerotherapy. METHODS AND MATERIALS: A total of 230 lower limbs from 115 patients with telangiectasias classified as C1 according to the Clinical-Etiological-Anatomical-Pathophysiological classification were included. Patients underwent liquid sclerotherapy with and without skin cooling during the procedure. Pain was assessed using a visual analog scale, applied immediately after the procedure, according to each lower limb area treated. RESULTS: Visual analog scale pain scores were significantly lower for sclerotherapy with the use of cooling for pain management during the procedure than for sclerotherapy without cooling both in the thigh and leg (p < .0001). CONCLUSION: The use of a cooling system is effective in reducing pain in patients undergoing liquid sclerotherapy of telangiectasias, providing more comfort to patients.

Treatment of aneurysms in the splenic and renal arteries in a single operation: case report and review.

Visceral and renal artery aneurysms are rare (0.01 to 2%) and their risk of rupture varies between different types and depending on their anatomy and patient context (comorbidities, pregnancy, and liver transplant history). Mortality due to rupture of these aneurysms is around 25%. New techniques and materials derived from neurointervention seem to be promising options for treatment of these aneurysms. In this context, we report the case of a patient undergoing endovascular treatment of both splenic artery and renal artery aneurysms during the same procedure, using Solitaire stents and controlled release coils in both repairs. The patient recovered well with both aneurysms adequately treated. In conclusion, endovascular treatment of splenic and renal artery aneurysms during the same operation is feasible and has proved safe and effective in the case reported.

Endovascular treatment of a teenager with nutcracker syndrome: a case report.

The nutcracker syndrome is caused by compression of the left renal vein by the superior mesenteric artery and aorta and is associated with characteristic symptoms, such as lower abdominal pain, varicocele, and hematuria. Diagnosis is often difficult and, therefore, is often delayed. Invasive treatment is controversial, particularly in pediatric patients. However, it is indicated in cases of gross hematuria associated with anemia, renal function impairment, severe pelvic pain, or ineffective conservative treatment. We report the case of a 12-year-old boy presenting with severe hematuria for 12 hours, with no abnormal findings at a first evaluation, who progressed with severe anemia and urinary retention. Further investigation provided images suggestive of nutcracker syndrome, and endovascular stenting (smart control stent) followed by balloon dilatation was the treatment of choice. Hematuria ceased after the procedure, and the patient is still asymptomatic at 5-year follow-up.

Superior vena cava syndrome: endovascular management.

BACKGROUND: The objective of management of superior vena cava syndrome (SVCS) is to promptly alleviate the uncomfortable symptoms. Conventional approaches do not always achieve results as rapidly as endovascular management with stent placement. OBJECTIVES: To report the experience with endovascular management of SVCS of a Vascular and Endovascular Surgery Service at a Brazilian university hospital. METHODS: Symptomatic type III SVCS cases were managed with angioplasty and stent placement in 28 patients aged from 37 to 68 years, between 2002 and 2012. The etiology of SVCS was lung or thoracic cancer in 18 patients, while occlusion of the vein for prolonged use of catheters was the cause in the other 10 cases. RESULTS: Superior vena cava occlusion repair was not possible in one oligosymptomatic patient with a very severe lesion. Technical success was achieved in 96.4%. There were two deaths, one due to pulmonary embolism, 24 hours after a successful procedure, and the other due to compression of the airways by tumor mass some hours after the procedure. Clinical success was achieved in all cases of technical success, including one patient who died suddenly, after total regression of SVCS symptoms. Symptoms disappeared 24 hours and 48 hours after management in16 and 8 patients respectively; improvement was slower but progressive after 48 hours in the remaining patients. CONCLUSIONS: Endovascular stent placement was effective for management of SVCS, with good technical and clinical success rates and provided prompt relief from symptoms.

CONTEXTO: O tratamento da síndrome da veia cava superior (SVCS) visa aliviar, rapidamente, os sintomas desconfortáveis. Os resultados das abordagens convencionais nem sempre são tão rápidos quanto os do tratamento endovascular com colocação de stent. OBJETIVOS: Relatar a experiência de um Serviço de Cirurgia Vascular e Endovascular de hospital universitário brasileiro com o tratamento endovascular da SVCS. MÉTODOS: Vinte e oito pacientes com SVCS sintomática tipo III foram tratados com angioplastia e colocação de stent, entre 2002 e 2012. A idade variou entre 37 e 68 anos. A SVCS resultou de doença neoplásica pulmonar ou torácica em 18 pacientes e de oclusão da veia por uso prolongado de cateteres em 10 pacientes. RESULTADOS: Não foi possível reparo da oclusão da veia em um paciente oligossintomático com lesão bastante grave. O sucesso técnico foi de 96,4%. Houve duas mortes, sendo uma por embolia pulmonar 24 horas após procedimento bem-sucedido e outra por compressão das vias aéreas por massa tumoral algumas horas após o procedimento. Houve sucesso clínico em todos os casos de sucesso técnico, incluindo o paciente que faleceu de repente após ter apresentado regressão total dos sintomas. Os sintomas desapareceram em 24 e 48 horas após o tratamento em, respectivamente, 16 e oito pacientes. A melhora foi mais lenta, embora progressiva, após 48 horas nos demais pacientes. CONCLUSÕES: A colocação de stent endovascular no tratamento da SVCS foi eficaz, com boas taxas de sucesso técnico e clínico e alívio mais rápido dos sintomas.

Endovascular treatment for Behçet's disease: a case report.

Behçet's disease (BD) is a multisystemic vasculitis of unknown etiology. Cardiovascular involvement has been thoroughly described in the literature and the major cause of death in BD is secondary to aneurysm complications. In this case report, a patient with BD presented with a recurrent abdominal aortic aneurysm, which was corrected using a custom-made endoprosthesis. The optimal treatment for patients with BD remains highly controversial and challenging because of technical difficulties and frequent recurrence. Endovascular intervention seems to be a feasible alternative with considerably less morbidity than conventional surgery.

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.

Renal arteriovenous fistula after renal biopsy: a case report and literature review.

Acquired renal arteriovenous fistulas (AVF) are rare conditions in which an anomalous connection arises between the arterial and venous systems. Renal AVFs can be classified into three main groups: idiopathic, congenital, and acquired, the last of which are the most common. Incidence has been increasing, due to the growing number of renal biopsies. Although the renal biopsy procedure is relatively safe nowadays, one possible complication is formation of an AVF in the renal vascular territory. Treatment of renal AVF is widely discussed in the literature and a variety of treatment methods can be employed. We report a case of arteriovenous fistula after renal biopsy that was successfully treated with endovascular coil embolization.

Treatment of type 1A endoleak using coil embolization: a case report.

In a type 1A endoleak, the endograft is unable to fully seal the proximal aneurysm neck and blood flow leaks between the wall of the aortic neck and the graft material. This article reports a case in which coil embolization was used and presents a literature review (PubMed, LILACS, and SciELO). Searches were run for articles published in the past 5 years using the descriptors "endoleak 1A", "coil embolization," and "treatment". Type 1A endoleak occurs in 1.1% of patients within 30 days of graft placement. Treatment of an endoleak is obligatory and usually consists of sealing the proximal graft neck using stents and balloons to expand the landing zone or to increase the radial force of the graft. Some studies have suggested using embolization techniques with cyanoacrylate, fibrin glue, and Onyx, demonstrating success rates that exceed 97%. However, correction of type 1A endoleak using coil embolization has seldom been described.

Pulmonary sequestration and endovascular treatment: a case report.

Pulmonary sequestration is a congenital anomaly defined as a nonfunctioning mass of lung parenchyma. Presence of an independent pleural envelope classifies it as intralobar, accounting for approximately 75% of the cases, while absence classifies cases as extralobar, accounting for the remaining 25%. Diagnosis is made through radiography and confirmed by computed tomography, magnetic resonance, or angiography. The traditional treatment is open surgical repair, but endovascular techniques have been used, with good results. We report the case of a 29-year-old-woman presenting with recurrent pneumonia for 5 years. A CT scan of the chest revealed poor vascular formation in the lower region of the right lung. The pulmonary sequestration was treated by embolization of the anomalous branch.

Type II Endoleaks, Left-Arm Complications, and Need of Revascularization after Left Subclavian Artery Coverage for Thoracic Aortic Aneurysms Endovascular Repair: A Systematic Review.

BACKGROUND: The status of the left arm, the need of revascularization, and the occurrence of type II endoleakes from de left subclavian artery (LSA) after intention LSA coverage for thoracic aortic aneurysm endovascular repair need to be better understood. This systematic review was developed for contributing with such issue. METHODS: Systematic literature review of studies published from January 2000 through December 2015 identified 7 studies comprising 201 patients submitted to elective endovascular repair for thoracic aortic aneurysms requiring intentional LSA coverage. Outcomes of interest included left-arm complications (ischemia, symptoms of claudication, and subclavian steal syndrome [SSS]) requiring postoperative revascularization of LSA, as well as endoleaks from the subclavian artery requiring postoperative embolization of LSA. RESULTS: Left-arm complication rate was 4.5% (9 patients), requiring postoperative revascularization of LSA in 1 case (0.5%) of SSS. Type II endoleaks from the subclavian artery requiring postoperative embolization of LSA were reported in 2 cases (1.0%). CONCLUSIONS: Low-quality evidence suggests very low rates of arm complications with need of LSA revascularization and of type II endoleaks requiring embolization in elective endovascular treatment of thoracic aortic aneurysms with intentional coverage of LSA without prophylactic revascularization of LSA.

Optimized Protocol for Fast CT Angiography of Lower Limbs Using 160-Row Detector.

OBJECTIVE: We proposed and tested a novel acquisition protocol for optimizing a fast computed tomography angiography using a 160-row detector scanner using a longer contrast injection time coupled with multiphasic rate of injection. METHODS: A prospective randomized study was performed to compare image quality, contrast enhancement, and radiation dose in 2 groups (a fast acquisition and a widely accepted slow acquisition). RESULTS: There was no difference between groups regarding image quality, noise, and diagnostic performance, but we evidenced a trend to higher radiation dose for the fast acquisition protocol. CONCLUSIONS: An optimized protocol for performing a fast acquisition computed tomography angiography of lower limbs is feasible, has sufficient diagnostic quality, and can be used in selected patients who would benefit from a short-time scan.

Histologic analysis of stent graft oversizing in the thoracic aorta.

OBJECTIVE: To elucidate the histologic changes after stent graft oversizing in nonatherosclerotic aortas using an experimental porcine model. We previously reported that the diameter and angulation of the aorta in this model are similar to those in young individuals who undergo stent graft repair for blunt aortic injuries. The lack of commercially available stent grafts specific for repairing blunt aortic injuries, particularly for small and angulated aortas, may be related to the high rate of endograft complications in this population. METHODS: Twenty-five pigs were randomized into one control group (without stent graft implantation) and four oversized groups (A: 10%-19%, B: 20%-29%, C: 30%-39%, and D: >40%). Three circumferential fragments were collected from the aorta for histologic and immunohistochemical studies. Morphometric analyzes were performed using an inflow system and image analysis software (Quantimet 500; Leica Cambridge Ltd, Cambridge, UK). RESULTS: Collagen expression in the aortic wall was not significantly different among the five groups (P = .5604). There were significantly fewer muscle fibers in the aortic wall in the oversized groups compared with the control group (P = .000198). The proportion of elastic fibers in the aortic wall was significantly smaller in the oversized groups compared with the control group (P = .0000001). Immunohistochemical analysis showed that α-actin expression in the aortic wall was significantly decreased in the oversized groups compared with the control group (P = .002031). There were no significant differences in either the number of muscle fibers or α-actin expression among the four oversized groups. CONCLUSIONS: Histologic and immunohistochemical studies confirmed the structural disarrangement of the aortic wall after insertion of an endoprosthesis, including reduced number of muscle and elastic fibers.

Association between obesity and the aggravation of limited range of ankle mobility in chronic venous disease.

AIM: The aim of the present study was to show that an increase in weight leads to the aggravation of limited joint mobility. METHOD: One hundred sixteen patients with varicose veins of the lower limbs and body mass index (BMI) higher than 30 kg/m2 were evaluated at the Belczak Clinic in Maringá, Brazil. All patients were evaluated by the same physician, and the goniometric readings were performed on all patients by a physiotherapist. The participants were then divided into three groups based on BMI: Group I-BMI between 30 and 40. Group II-BMI between 40 and 50, and Group III-BMI > 50. RESULTS: There is a significant difference between the groups detected. CONCLUSION: The present findings show that an increased BMI in obese individuals with chronic venous disease is associated with a progressive limitation of ankle mobility.