Calógero Presti

A practical protocol to measure common carotid artery intima-media thickness

OBJECTIVE To describe and test a practical protocol to measure common carotid intima-media thickness that uses the combined values of two longitudinal examination angles to increase sensitivity. METHOD Between February and September 2005, 206 patients underwent duplex scan examination of carotid vessels, and the intima-media thickness of 407 common carotids were measured in three angles: transversal, longitudinal posterolateral, and anterolateral, with three intima-media thickness measurements for each near and far wall. In addition to numbers obtained from the three angles of measurement, a fourth visual perspective was obtained by combining the intima-media thickness results of posterolateral and anterolateral longitudinal views and considering the thickest wall measurement. RESULTS Two hundred seventy (66.3%) carotid arteries had an intima-media thickness thicker than 1mm. The mean intima-media thickness values achieved by the different incidences were 1.26±0.6mm (transversal), 1.17±0.54mm (longitudinal anterolateral), and 1.18±0.58mm (longitudinal posterolateral). A significant difference in intima-media thickness measurement values was observed when the three angles of examination plus the combined positive results of both longitudinal angles were compared by ANOVA (P=0.005). The LSD Post-Hoc test determined that the combined longitudinal view results were similar to the transversal views (P=0.28) and had greater intima-media thickness means than isolated anterolateral or posterolateral longitudinal views (P=0.02 and 0.05, respectively). CONCLUSIONS The protocol presented is a practical method for obtaining common carotid artery intima-media thickness measurements. The combined longitudinal posterolateral and anterolateral longitudinal views provide a more sensitive evaluation of the inner layers of the carotid walls than isolated longitudinal views.

Doença arterial obstrutiva periférica: que atenção temos dispensado à abordagem clínica dos pacientes?

OBJETIVO: Avaliar como pacientes com doenca arterial obstrutiva periferica tem sido tratados, em nosso meio, com relacao aos fatores de risco e comorbidades. METODO: Questionario sobre pesquisa e tratamento da dislipidemia, diabetes, exercicio, uso de anti-plaquetarios, tabagismo e hipertensao arterial no paciente com doenca arterial obstrutiva periferica foi aplicado entre os medicos presentes na reuniao mensal de marco de 2004 da Sociedade Brasileira de Angiologia e Cirurgia Vascular - Regional Sao Paulo. RESULTADOS: Dos 102 questionarios distribuidos, 75 foram respondidos (taxa de resposta de 73,5%). Entre os consultados, 82% pesquisam rotineiramente perfil lipidico e 20% visam alvo de LDL-colesterol abaixo de 100 mg/dl; 94% realizam pesquisa para diabetes melito; 97% recomendam exercicio; 79% prescrevem aspirina; 97% aconselham que os pacientes parem de fumar e 60% se restringem ao aconselhamento isoladamente; 18% nao realizam a medida da pressao arterial durante a consulta e 19% visam alvo pressorico de 130 x 80 mmHg. Considerando todas as avaliacoes em conjunto - intervencao no estilo de vida, no sentido de parar de fumar, orientacao de exercicios, uso de anti-plaquetarios, realizacao de pesquisa para diabetes melito, controle rigoroso da pressao arterial e lipides - observou-se que 7% dos entrevistados seguem todas essas recomendacoes como uma rotina estabelecida. CONCLUSAO: O presente estudo demonstrou que, em nosso meio, a pesquisa e o tratamento dos fatores de risco e comorbidades nos pacientes com doenca arterial obstrutiva periferica estao sendo sub-realizados.

Incidence of ipsilateral postoperative deep venous thrombosis in the amputated lower extremity of patients with peripheral obstructive arterial disease

OBJECTIVE Patients undergoing amputation of the lower limb due to peripheral arterial disease (PAD) are at risk of developing deep venous thrombosis (DVT). Few studies in the research literature report the incidence of DVT during the early postoperative period or the risk factors for the development of DVT in the amputation stump. This prospective study evaluated the incidence of DVT during the first 35 postoperative days in patients who had undergone amputation of the lower extremity due to PAD and its relation to comorbidities and death. METHODS Between September 2004 and March 2006, 56 patients (29 men), with a mean age of 67.25 years, underwent 62 amputations, comprising 36 below knee amputations (BKA) and 26 above knee amputations (AKA). Echo-Doppler scanning was performed preoperatively and on postoperative days 7 and 31 (approximately). All patients received acetylsalicylic acid (100 mg daily) preoperatively and postoperatively, but none received prophylactic anticoagulation. RESULTS DVT occurred in 25.8% of extremities with amputations (10 AKA and 6 BKA). The cumulative incidence in the 35-day postoperative period was 28% (Kaplan-Meier). There was a significant difference (P = .04) in the incidence of DVT between AKA (37.5%) and BKA (21.2%). Age >or=70 years (48.9% vs 16.8%, P = .021) was also a risk factor for DVT in the univariate analysis. Of the 16 cases, 14 (87.5%) were diagnosed during outpatient care. The time to discharge after amputation was averaged 6.11 days in-hospital stay (range, 1-56 days). One symptomatic nonfatal pulmonary embolism occurred in a patient already diagnosed with DVT. There was no relation between other comorbidities and DVT. The multivariate analysis showed no association between risk factors and the occurrence of DVT in the amputated extremity. DVT ipsilateral to the amputation did not influence the mortality rate (9.7%). CONCLUSION The incidence of DVT in the early postoperative period (<or=35 days) was elevated principally in patients aged >or=70 years and for AKA. Patients with PAD who have recently undergone major amputations should be considered at high risk for DVT, even after hospital discharge. Given the high rate of postoperative DVT observed in this study, we now recommend prophylactic anticoagulation for these patients, but further study is needed to determine the optimal duration and efficacy of this treatment.

Comparison of common carotid artery intima-media thickness between Brazilian Euro-descendants and Afro-descendants with atherosclerosis risk factors

OBJECTIVE: To compare common carotid intima-media thickness (IMT) between the two major Brazilian ethnic groups (those of African descent and those of European descent) among individuals with one or more risk factors for atherosclerotic disease. METHOD: Two hundred and six patients with one or more risk factors for atherosclerotic disease were evaluated in a cross-sectional study in which their clinical, ethnic and Demographic characteristics were collected. All patients underwent duplex ultrasound examination of their carotid vessels to obtain IMT measurements. RESULTS: One hundred and fifty-three patients (74.3%) had a carotid IMT greater than 1.0 mm at one or more point of measurement in at least one common carotid artery. There was a significant correlation between older age and mean carotid wall thickness (R=0.479 / P<0.01). Multivariate analysis identified male sex, arterial hypertension and older age as variables associated with increased IMT (P<0.05 for all variables). When IMT was compared between the two ethnic groups in this study, no significant differences were noted. Euro-descendants and Afro-descendants had similar IMT values, even when the groups were stratified by degree of IMT (normal vs. increased) and presence of stroke and/or transient ischemic attack (yes vs. no). CONCLUSIONS: The risk factors associated with increased common carotid artery IMT in Brazilian individuals are similar to those in previously described populations. No differences were observed between the two main Brazilian ethnic groups. Longitudinal studies are required for a better evaluation of the incidence, etiologic factors and evolution of carotid intimomedial thickening in this population.

Superficial femoral eversion endarterectomy combined with a vein segment as a composite artery-vein bypass graft for infrainguinal arterial reconstruction☆☆☆

OBJECTIVE The purpose of this study was to determine the results of composite artery-vein bypass grafting for infrainguinal arterial reconstruction. METHODS This study was designed as a retrospective case series in two tertiary referral centers. Forty-eight of 51 patients underwent the procedure of interest for the treatment of ischemic skin lesions (n = 42), rest pain (n = 3), disabling claudication (n = 1), and infected prosthesis (n = 2). The intervention used was infrainguinal composite artery-vein bypass grafting to popliteal (n = 18) and infrapopliteal (n = 30) arteries, with an occluded segment of the superficial femoral artery prepared with eversion endarterectomy and an autogenous vein conduit harvested from greater saphenous veins (n = 43), arm veins (n = 3), and lesser saphenous veins (n = 2). The main outcome measures, primary graft patency rates, foot salvage rates, and patient survival rates, were described by means of the life-table method for a mean follow-up time of 15.5 months. RESULTS The cumulative loss during the follow-up period was 6% and 24% at 6 and 12 months, respectively. The primary graft patency rates, the foot salvage rates, and the patient survival rates for patients with popliteal grafts were 60.0% +/- 9.07%, 75.7% +/- 9.18%, and 93.5% +/- 6.03%, respectively, at 1 month; 53.7% +/- 11.85%, 68.9% +/- 12.47%, and 85. 0% +/- 9.92% at 1 year; and 46.7% +/- 18.19%, 68.9% +/- 20.54%, and 53.1% +/- 17.15% at 5 years. For infrapopliteal grafts, the corresponding estimates were 72.4% +/- 7.06%, 72.9% +/- 6.99%, and 92.7% +/- 4.79% at 1 month; 55.6% +/- 10.70%, 55.4% +/- 10.07%, and 77.9% +/- 9.02% at 1 year; and 33.6% +/- 22.36%, 55.4% +/- 30.20%, and 20.8% +/- 9.89% at 5 years. CONCLUSION The composite artery-vein bypass graft is a useful autogenous alternative for infrainguinal arterial reconstruction when a vein of the required quality is not available or when the procedure needs to be confined to the affected limb.

A duplex scan-based morphologic study of the femoral vein: Incidence and patterns of duplication

The presence of femoral vein (FV) duplicity has potential influence in the misdiagnosis of deep vein thrombosis. Also, FVs are suitable vascular substitutes, especially in the substitution of infected prosthetic grafts. The objective of this study was to describe the prevalence, anatomic patterns and characteristics of FV duplicity in adult individuals by duplex scan examination. A total of 174 adult individuals were submitted to duplex-scan examinations of both lower limbs. Individuals with duplex signs of present or previous DVT or with poor quality duplex images were excluded from the investigation. The remaining group consisted of 157 individuals (94 females), with a total of 314 limbs studied. Along with the conventional duplex investigation sequence, the FV was scanned both in transversal and longitudinal views. The number, extension and diameter of FVs were documented. It was found that 173 limbs (55.1%) had duplicated FV. Duplicity in the whole femoral extension was noted in 82 (26.1%) limbs, and out of these only 28 (8.9% of the overall number) had accessory veins with a diameter approximate to (at least 75%) the main FV. Partial (distal or proximal) duplications were seen in 89 (28.3%) limbs. A third FV was present in 28 limbs. As a possible vascular substitute, 99.0% of the main FVs and 25.4% of the accessory veins presented diameters superior to 6 mm, a suitable value for iliac substitution. In conclusion, FV duplicity is frequent, and occurred in 55% of all limbs studied. However, complete extension duplicated veins with similar diameters was an uncommon condition, noticed in fewer than 10% of limbs.

Late results of catheter-directed recombinant tissue plasminogen activator fibrinolytic therapy of iliofemoral deep venous thrombosis

PURPOSE To evaluate the efficacy of catheter-directed low-dose recombinant tissue-type plasminogen activator infusion in the treatment of iliofemoral deep venous thrombosis and prevention of post-thrombotic syndrome. METHOD Eighteen patients (out of 260 evaluated) with acute iliofemoral deep venous thrombosis and no previous evidence of venous insufficiency were prospectively selected for thrombolytic therapy. Catheter-directed low-dose recombinant tissue-type plasminogen activator (1 mg/h) was infused into the thrombotic segments. RESULTS Effective fibrinolysis was achieved in 14 of 18 cases, with correlation between effective fibrinolysis and major/complete resolution of acute signs and symptoms (P <.01). There were no episodes of major complications. Four patients presented with early rethrombosis (1 to 8 weeks). Individuals were followed for a period up to 131 weeks (average, 85.2). The incidence of clinical signs and symptoms of venous insufficiency and duplex-scan findings of valvular reflux was significantly lower in the patients in which lytic therapy succeeded and patency was kept, compared with patients experiencing acute therapeutic failure or rethrombosis (P <.01). CONCLUSIONS Low-dose recombinant tissue-type plasminogen activator fibrinolytic therapy is safe and effective in the treatment of acute iliofemoral venous thrombosis. The late evolution as revealed clinically and by ultrasound was superior in patients for whom lytic therapy was effective.

Long-Term Comparison of in Situ and Nonreversed Saphenous vein Grafts for Infrapopliteal Reconstruction

The nonreversed saphenous vein bypass graft has become a reasonable alternative to the standard in situ technique for infrainguinal arterial reconstruction. The objective of this study was to compare the long-term results obtained with these techniques in patients with severe limb ischemia. Fifty-five in situ and 57 nonreversed saphenous vein bypass grafts to the infrapopliteal arteries were compared for secondary graft function, preser vation of the foot, and patient survival. The crude relative risk of secondary failure for nonreversed grafts was 1.03 (95% confidence interval [95%CI] 0.62-1.69). Stratified analysis showed a stable relative risk of 1.04 (95%CI 0.58-1.86) in the stratum of 33 nonreversed and 47 in situ grafts done with both a good vein and a high origin. Conflicting results were found in the other strata as a result of small stratum size. The relative risks for major amputation and death were 0.60 (95%CI 0.35-1.05) and 0.44 (95%CI 0.25-0.79), respectively.

Comparison between a new computer program and the reference software for gray-scale median analysis of atherosclerotic carotid plaques.

To compare a new dedicated software program and Adobe Photoshop for gray‐scale median (GSM) analysis of B‐mode images of carotid plaques.

Technique of Aortic Replacement Through Endovascular Stenting Before Aortic Wall Resection for Primary Leiomyosarcoma of the Abdominal Aorta

Tumors involving the aorta represent a challenging situation because the surgical approach can lead to blood loss and/or clamping-related complications such as ischemia, thrombosis, or reperfusion syndromes. We describe the technique of aortic endograft placement to cover part of the abdominal aorta and provide conditions for extensive aortic wall resection, without clamping or blood loss, followed immediately by aortic reconstruction with bovine pericardium. This technique also allows the surgeon to wait for the results of freeze biopsy without additional clamping time, thus avoiding the risk of leaving residual tumor cells in the aortic wall.