Carlos Alberto Engelhorn

Intima-media thickness in the origin of right subclavian artery as an early marker of cardiovascular risk

OBJECTIVE: Common carotid artery intima-media thickness (IMT) is considered a factor of cardiovascular risk and an early marker of coronary artery disease. This study aimed to investigate the existence of a correlation between IMT in the carotid arteries and at the origin of the right subclavian artery, as well as to evaluate IMT in the subclavian artery as an earlier marker of cardiovascular risk. METHODS: One hundred and six consecutive patients, 52 males and 54 females, average age 51 years, underwent color Doppler ultrasonography to evaluate carotid and right subclavian arteries. The relationship between carotid IMT and right subclavian IMT was assessed using the Pearsons correlation coefficient analysis and a 95% confidence interval. Reliability of right subclavian artery IMT measurement for the diagnosis of early thickening (considering a > 0.8 mm carotid thickness as reference) was described as to sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Cut-off values for the right subclavian IMT were indicated by the ROC curve, and p values 0.8 mm. The mean IMT value for the carotid artery was 0.87 mm (SD = 0.23) and for the subclavian artery, 1.17 mm (SD = 0.46), with a 0.31 correlation coefficient (95% CI: 0.12; 0.47). The ROC curve analysis indicated a cut-off value of 0.7 mm for the right subclavian artery IMT, using as reference a 0.8 mm cut-off value for the carotid artery (91% sensitivity, 27% specificity, 66% PPV, 65% NPV, and 66% accuracy). CONCLUSION: Our study showed that carotid artery IMT correlates well with right subclavian artery IMT. With a 0.7 mm cut-off value, it is possible to detect IMT in the right subclavian artery earlier than in the carotid arteries. The IMT at the origin of the right subclavian artery can be considered an earlier marker for the assessment of cardiovascular risk.OBJECTIVE Common carotid artery intima-media thickness (IMT) is considered a factor of cardiovascular risk and an early marker of coronary artery disease. This study aimed to investigate the existence of a correlation between IMT in the carotid arteries and at the origin of the right subclavian artery, as well as to evaluate IMT in the subclavian artery as an earlier marker of cardiovascular risk. METHODS One hundred and six consecutive patients, 52 males and 54 females, average age 51 years, underwent color Doppler ultrasonography to evaluate carotid and right subclavian arteries. The relationship between carotid IMT and right subclavian IMT was assessed using the Pearsons correlation coefficient analysis and a 95% confidence interval. Reliability of right subclavian artery IMT measurement for the diagnosis of early thickening (considering a > 0.8 mm carotid thickness as reference) was described as to sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Cut-off values for the right subclavian IMT were indicated by the ROC curve, and p values < or = 0.05 were considered statistically significant. RESULTS Out of the 41 patients whose carotid arteries were IMT-free, 30 (73%) had right subclavian artery IMT values > 0.8 mm. The mean IMT value for the carotid artery was 0.87 mm (SD = 0.23) and for the subclavian artery, 1.17 mm (SD = 0.46), with a 0.31 correlation coefficient (95% CI: 0.12; 0.47). The ROC curve analysis indicated a cut-off value of 0.7 mm for the right subclavian artery IMT, using as reference a 0.8 mm cut-off value for the carotid artery (91% sensitivity, 27% specificity, 66% PPV, 65% NPV, and 66% accuracy). CONCLUSION Our study showed that carotid artery IMT correlates well with right subclavian artery IMT. With a 0.7 mm cut-off value, it is possible to detect IMT in the right subclavian artery earlier than in the carotid arteries. The IMT at the origin of the right subclavian artery can be considered an earlier marker for the assessment of cardiovascular risk.

Does the number of pregnancies affect patterns of great saphenous vein reflux in women with varicose veins

Objectives Impact of pregnancies on great saphenous vein (GSV) reflux patterns deserves clarification. Which GSV segment is most affected? Is the saphenofemoral junction (SFJ) involved? Methods Colour-flow duplex ultrasonography was performed in 583 women extremities with primary varicose veins (clinical, aetiological, anatomical and pathological elements [CEAP C2]), without oedema, skin changes or ulcer. Women with previous thrombosis or varicose surgery were excluded. GSV reflux sources and drainage points were located at SFJ, thigh, knee and calf. Prevalence of most proximal reflux source was noted as a function of 0, 1, 2, 3 and 4 or more pregnancies. χ2 statistics was employed. Results Prevalence of GSV reflux was not dependent on 0, 1, 2, 3 or ≥4 pregnancies: 75%, 69%, 79%, 70% and 76% for right leg (P = 0.79) and 78%, 81%, 82%, 79% and 73% for left leg (P = 0.87), respectively. Prevalence of SFJ reflux and GSV reflux, starting at the thigh, knee or calf, was similar and showed no tendencies to increase with number of pregnancies. Conclusions Number of pregnancies did not influence GSV reflux patterns in women with primary varicose veins.

Vascular Color Doppler Ultrasound for Assessing Renovascular Hypertension. Accuracy of the Direct Technique for Assessing the Renal Arteries

OBJECTIVE To assess the accuracy of vascular color Doppler ultrasound as compared with digital subtraction arteriography for identifying hemodynamically significant renal artery stenoses. METHODS One hundred and thirty-seven renal arteries from 69 adult patients suspected of having renovascular arterial hypertension were prospectively studied with ultrasound. The results obtained were compared in a double-blind manner with those obtained on digital subtraction arteriography, and the following parameters were calculated according to previously defined criteria: sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy. RESULTS The inconclusive results (7 arteries) were excluded. The comparison of the 2 methods in regard to the 130 remaining arteries showed concordant results for 116 (89.2%) arteries and discordant results for 14 (10.8%) arteries. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of vascular color Doppler ultrasound were, respectively, 95.33%, 88.14%, 89.86%, 94.55%, and 91.94%. CONCLUSION A good correlation between the 2 examinations was observed in the evaluation of the hemodynamically significant renal artery stenoses, making vascular color Doppler ultrasound a noninvasive method useful for selecting patients with suspected renovascular hypertension.

Progression of reflux patterns in saphenous veins of women with chronic venous valvular insufficiency

Background Venous ultrasonography identifies reflux patterns of the great and small saphenous veins (GSV, SSV), allowing evaluation of lower extremities for treatment planning and patient follow-up. Objective To determine progression of saphenous vein reflux patterns in women with primary venous valvular insufficiency. Methods Venous ultrasonography was performed in the extremities of 92 women, 43 ± 12 (23–77) years old, CEAP (clinical, aetiological, anatomical and pathological elements) clinical classes C1–C2. Two examinations were performed 33 ± 19 (8–89) months apart in patients without saphenous vein treatment. GSV and SSV reflux patterns were classified as segmental, multisegmental, distal, proximal, diffuse and normal. Prevalence was determined for each examination, separately for right and left extremities, and jointly. Prevalence was compared using χ2 statistics. Results Reflux prevalence was higher for the GSV, 89% (164/184) and 88% (n = 162), than for the SSV, 24% (n = 45) and 30% (n = 56), respectively for first and second examinations (P < 0.001). Reflux pattern prevalence was not significantly different in the right and left extremities (1.0 > P > 0.14). Most prevalent patterns were (a) GSV segmental reflux initially, 41% (76/184), decreasing to 28% (52/184) (P = 0.009), and (b) GSV multisegmental reflux at the second examination, increasing from 26% (48/184) to 40% (73/184) (P = 0.006). Prevalence of other GSV or SSV reflux patterns did not change significantly (0.88 > P > 0.19). Conclusions We documented early findings and venous reflux progression in a specific population of women with varicose veins, reticular veins and telangiectasias. GSV segmental reflux was most prevalent initially, progressing to GSV multisegmental reflux.

Avaliação da aterosclerose subclínica e de níveis plasmáticos de LDL minimamente modificada em pacientes com espondilite anquilosante e sua correlação com a atividade da doença

INTRODUCTION Accelerated atherosclerosis has been shown in some autoimmune diseases, mainly in Systemic Lupus Erythematosus and Rheumatoid Arthritis. Although high prevalence of corticosteroids use may be a confounding factor due to their detrimental effects on several risk factors, systemic inflammation per se is supposed to play an important role in atherogenesis in these patients. METHODS We have evaluated sub-clinical atherosclerosis and plasma levels of circulating electronegative LDL, which represents the fraction of LDL that is minimally modified, in patients with ankylosing spondylitis (AS). Fourteen patients who fulfilled the modified New York criteria for AS were compared with 13 paired controls. Carotid intimal-media thickness (IMT) was assessed by ultrasonography bilaterally in common carotid artery, internal carotid artery and in the bifurcation. Groups were homogeneous regarding cardiovascular risk factors. Only a single patient in AS group was in use of corticosteroid. RESULTS The presence of active inflammation was demonstrated by elevated BASDAI and higher CRP levels and in patients versus controls (12.36 vs. 3.45 mg/dl, P = 0.002). No difference was found in carotid IMT between both groups, in any site of artery. Averaged IMT (6 measurements, at 3 pre-specified sites bilaterally) was 0.72 ± 0.28 in AS group and 0.70 ± 0.45 mm in controls (P = 0.91). Minimally modified LDL did not differ significantly either between patients and controls (14.03 ± 17.40 vs. 13.21 ± 10.21; P = 0.88). CONCLUSIONS Patients with AS did not show increased carotid IMT in comparison to controls. In the same way, circulating plasma levels of LDL (-), did not differ significantly in both groups.

Probabilidade de refluxo nas veias safenas de mulheres com diferentes graus de insuficiência venosa crônica

CONTEXTO: A presenca de refluxo nas juncoes safeno-femoral e safeno-poplitea e um dado importante para programacao da cirurgia de varizes. Estudos mostraram que, na maioria dos pacientes com insuficiencia venosa cronica, as juncoes estao competentes, e o refluxo esta presente ao longo do trajeto das veias safenas. OBJETIVOS: Identificar probabilidade de diferentes padroes de refluxo nas veias safenas de mulheres com varios graus de insuficiencia venosa cronica e avaliar se o comprometimento das juncoes das safenas esta associado com gravidade da insuficiencia venosa. METODOS: Um total de 1.184 membros inferiores de 672 mulheres foram estudados pela ultra-sonografia vascular com Doppler colorido e avaliados pela classificacao clinica, etiologica, anatomica e patologica (CEAP). As extremidades foram agrupadas de acordo com a gravidade da insuficiencia venosa em graus leve (CEAP C1-C2), moderado (CEAP C3) e grave (CEAP C4-C6). Para avaliar a classificacao clinica CEAP na predicao do padrao de refluxo, utilizou-se o Teorema de Bayers. Para avaliar associacao entre classificacao clinica CEAP e padroes de refluxo com ou sem comprometimento das juncoes das safenas, utilizou-se o teste qui-quadrado (p < 0,05). RESULTADOS: Das 1.184 extremidades avaliadas, 50,2% apresentavam varizes sem edema (CEAP C2). O padrao de refluxo segmentar foi o mais frequente nas veias safenas magna (35,14%) e parva (8%), independente da gravidade da insuficiencia venosa. As juncoes safeno-femoral e safeno-poplitea foram fontes de refluxo em 12 e 6% das extremidades, respectivamente. Considerando a associacao entre classificacao clinica CEAP e insuficiencia das juncoes das safenas, foi observada diferenca significativa entre presenca de refluxo nas juncoes safeno-femoral (p = 0,0009) e safeno-poplitea (p = 0,0006) na doenca avancada. CONCLUSOES: O refluxo inicia-se predominantemente em segmentos no trajeto das veias safenas. As juncoes das safenas nao sao as principais fontes causadoras do refluxo no sistema venoso superficial. A medida que piora a apresentacao clinica da insuficiencia venosa, aumenta a probabilidade de refluxo nas juncoes das safenas.

Ultrasonographic Tissue Characterization of Kidneys in Patients with Unilateral Renal Artery Stenosis

Introduction Ultrasound tissue characterization (USTC) has been applied to B-mode images of normal, young and transplanted kidneys, carotid, and peripheral atherosclerosis and venous thrombosis. We analyzed USTC from both kidneys of patients with severe unilateral renal artery stenosis. Seven women and 11 men, 79 ± 9 standard deviation (range = 57–96) years of age, were included. Severe, unilateral, renal artery stenosis was based on renal artery peak-systolic velocity (PSV) > 200 cm/sec and/or renal-aortic PSV ratio > 3.5. This sample population, selected sequentially by date of ultrasonographic examinations requested, was heterogeneous: kidney lengths and resistivity indices varied from 6.7 to 13.4 cm and 0.45 to 0.85. Methods USTC was applied to images selected for kidney length measurements. Pixel brightness in the 0–255 range was rescaled to zero for black and 200 for fascia brightness. Gray-scale medians (GSM) of entire kidneys were estimated for statistical comparisons between: (a) kidneys ipsilateral to stenosis (KIS), (b) kidneys contralateral to stenosis (KCS), and (c) normal, young kidneys (KN), previously published GSM = 37 ± 6 (27–48). Results Two distinct KCS subgroups were identified: (1) near-normal GSM < 54 (KCSN, n = 10, 56%); and (2) elevated GSM > 60 (KCSH, n = 8, 44%). Subgroup increasing GSM order was (1) KN, (2) KCSN (47 ± 7, > KN, p < 0.002), (3) KIS-CN (59 ± 20, >KCSN, p < 0.003), (4) KIS-CH (73 ± 20, > KCSN, p < 0.007), and (5) KCSH (78 ± 17, >KIS-CN, p < 0.05). GSM was independent of kidney length or resistivity index, with Pearson correlation coefficients < 0.5 for either KIS or KCS, respectively. Conclusions Tissue echogenicity, represented by GSM, was an independent variable characterizing effects of unilateral renal artery stenosis on the ipsilateral or on both kidneys.

Initial Evaluation of Virtual Histology Ultrasonographic Techniques Applied to a Case of Renal Transplant

Ultrasound virtual histology (USVH) techniques have been applied to B-mode images of coronary, carotid, and peripheral arteries and to deep venous thrombosis. We expanded USVH to evaluate the kidney. This case reports USVH applied to a renal transplant. A 29-year-old male with chronic renal insufficiency received his sisters kidney. B-mode images were recorded during (a) routine 1-day posttransplant US examination; and (b) a second follow-up US performed 6 days later once the patient became symptomatic. B-mode brightness of each pixel was classified into 14 ranges. USVH demonstrated high echogenicity of the kidney on day 1; gray scale median, GSM = 60, was elevated when compared with average GSM = 37 for normal, young kidneys. Muscle-like plus fiber-like echoes, 46 + 10 = 56%, were higher than expected for a normal young kidney, 34 + 3 = 37% (p = 0.0071). GSM increased to 88 on day 7. Normal resistivity indices (RI) on day 1 increased from 0.66–0.70 to 0.81–0.90. Biopsy confirmed kidney rejection. These findings confirmed the concepts that tissue changed before hemodynamics were altered and signs and symptoms developed. Ultrasonographic tissue characterization, particularly of transplanted kidneys, deserves extensive investigation focused on early changes that precede present-day detectable abnormalities.

Profilaxia medicamentosa da trombose venosa profunda em pacientes submetidos à cirurgia do trauma em um hospital universitário

BACKGROUND: Annually, millions of people are victims of trauma around the world. Besides the social and economic consequences caused by it, many of these patients need surgical treatment, thus generating greater risk to life. Venous thromboembolism, a consequence of deep vein thrombosis, represents a major cause of the morbidity and mortality in postoperative state, and it could be avoided with adequate prophylaxis. OBJECTIVE: To evaluate the use of chemoprophylaxis for deep vein thrombosis, in patients undergoing emergency trauma surgery in a teaching hospital. METHODS: A cross-sectional analytic study was conducted with 153 patients admitted to Cajuru University Hospital, in Curitiba, Parana, in a two-month period. Records of patients who required surgery due to trauma were prospectively analyzed. The study included those classified as high and medium risk for deep vein thrombosis. Then, it was identified whether or not the drug prophylaxis was used. A statistical analysis was descriptively performed. RESULTS: Of the 153 patients included, 99 (64.7%) were classified as high risk for deep vein thrombosis and 54 (35.3%) as medium risk. Of the total, 144 (94%) did not receive prophylaxis and nine (6%) did. On those who received prophylaxis, only four patients received the adequate. CONCLUSIONS: Prophylaxis of venous thrombosis disease is not performed routinely in patients of medium and high risk of developing deep vein thrombosis, who underwent trauma surgery. And, when performed, it is often inappropriate.

Estenose na artéria renal: a necessidade de validação dos critérios diagnósticos no laboratório vascular

OBJECTIVE: To validate the diagnostic criteria of color Doppler ultrasound in the identification of hemodynamically significant stenoses in renal arteries. METHODS: The color Doppler ultrasound was used to prospectively study 137 renal arteries of 69 adult patients suspected of having renovascular arterial hypertension. The results of the color Doppler ultrasound assessment were double-blindly compared to the arteriography. Cut-off values (ROC curve) were defined for systolic velocity, diastolic velocity and renal-aortic ratio, which better identify hemodynamically significant stenoses, at a Doppler angle of 60o. RESULTS: Peak systolic velocity higher than 250 cm/s was the parameter for greater accuracy (87.2%) in the identification of hemodynamically significant stenoses, followed by the renal-aortic ratio greater than 3.2 (85.6%) and peak diastolic velocity higher than 48 cm/s (70.4%). CONCLUSIONS: Parameters recommended in the literature must be validated in every vascular laboratory. For the ultrasound device and population included in this study, the diagnostic criteria for hemodynamically significant stenoses of renal arteries must be readjusted to systolic velocity > 250 cm/s and renal-aortic ratio > 3.2, at a Doppler angle of 60o.