Eduardo Lichtenfels

Profilaxia antimicrobiana em cirurgia vascular periférica: cefalosporina ainda é o padrão-ouro?

In peripheral vascular surgery, cephalosporins are nowadays regarded as the first choice for operative antibiotic prophylaxis. We have recently observed changes in colonizing patterns, pathogen prevalence and antibiotic susceptibility to antimicrobials. Multiresistant pathogens are becoming more frequent in vascular surgical wound infections, showing regional and local variations as to prophylactic antibiotic susceptibility. Data from the available literature so far have shown no strong evidence for a change in routine surgical antibiotic prophylaxis. We must consider regional and institutional prevalence of pathogen resistance and patterns of antibiotic susceptibility to establish specific guidelines for the use of alternative antibiotics.

Tratamento endovascular de aneurisma da artéria renal por embolização com micromolas preservando o fluxo sangüíneo renal: relato de caso

Endovascular treatment of renal artery aneurysmal disease has been increasingly accepted as an alternative to conventional surgery, especially in cases of renal artery bifurcation or complex intrarenal aneurysms. The authors report a case of endovascular treatment of a saccular aneurysm of the right renal artery bifurcation associated with poorly controlled renovascular hypertension. Selective catheterization of the renal artery was performed and microcoils were inserted into the aneurysmal sac. The aneurysm was completely obliterated with total preservation of renal blood flow. Clinical evolution was satisfactory with significant reduction in anti-hypertensive drugs. Control tomographic angiography, after eight months, confirmed treatment success.

Popliteal artery aneurysm surgery: the role of emergency setting.

The aim of this study was to compare the outcomes of emergent surgery caused by acute complications versus elective surgery of popliteal artery aneurysms (PAAs) and to evaluate the advantages of elective repair related to limb salvage and bypass patency rates. Fifty PAAs were operated on in 40 patients from January 2000 to December 2004. Surgery was elective in 34 cases (68%) and emergent in 16 (32%). Emergent repair was performed because of acute complications. All patients were treated surgically. Early results in terms of limb salvage, primary patency, and assisted patency were assessed. Follow-up consisted of clinical and/or ultrasonographic examinations at 10 days and 1, 3, 6, and 12 months and yearly thereafter. Long-term limb salvage and bypass patency rates were analyzed. The mean follow-up was 17 months. The 1-year limb salvage rate in the elective group was 97.1% versus 56.3% in the emergent group (P = .0007). The bypass patency rate at 1 year was 94.1% in the elective group versus 66.7% in the emergent group (P = .03). In this study, the outcomes of the PAA repair were significantly better in the group operated electively and without acute symptoms at presentation compared with the group with acute complications, operated on emergently, especially related to limb salvage and bypass patency rates.

Infecção em endoprótese

Infection involving stent grafts is an infrequent complication associated with high mortality rates. The clinical presentation is usually delayed and it may vary from nonspecific symptoms to severe complications such as pseudoaneurysm and aorto-enteric fistula. The diagnosis involves a high index of suspicion and investigation with imaging and laboratory exams. The treatment follows the precepts of graft infection in conventional surgery, and surgical excision is recommended for most patients, followed by in situ or extra-anatomic revascularization. Conservative treatment is reserved for selected cases.

Prevalência de resistência bacteriana nas infecções de ferida operatória em cirurgia arterial periférica

CONTEXTO: A infeccao de sitio cirurgico e uma complicacao grave da cirurgia vascular periferica. O recente aparecimento de microorganismos resistentes e agressivos gera uma nova preocupacao com relacao ao manejo dessas infeccoes. OBJETIVO: Verificar a prevalencia de resistencia bacteriana, a epidemiologia, os possiveis fatores associados e o padrao de resistencia nas infeccoes de ferida operatoria das cirurgias arteriais perifericas. METODOS: Estudo de prevalencia, envolvendo 40 pacientes portadores de infeccao da ferida operatoria e submetidos a cirurgia de revascularizacao arterial periferica no periodo de janeiro de 2007 a maio de 2008. RESULTADOS: Participaram do estudo pacientes com media de idade de 64,2 anos, predominantemente do sexo masculino (70%). A prevalencia geral de resistencia bacteriana foi 72,5%, e de multirresistencia, 60%. O microorganismo mais frequentemente isolado foi o Staphylococcus aureus (40%), sendo 11 das 16 culturas (68,7%) resistentes a oxacilina. As taxas de resistencia aos principais antimicrobianos testados foram: ampicilina, 85,7%; cefalosporina, 76,9%; oxacilina, 65%; e ciprofloxacina, 62,5%. Nao foi identificada resistencia a vancomicina e ao imipenem. CONCLUSOES: Os achados deste estudo sugerem que a resistencia bacteriana e um problema atual e muito prevalente nas cirurgias arteriais perifericas. O Staphylococcus aureus segue sendo o principal patogeno envolvido, demonstrando altas taxas de resistencia. A vancomicina e o imipenem seguem sendo as principais opcoes terapeuticas para esse tipo de infeccao.

Derivação arterial extra-anatômica no segmento aorto-ilíaco: experiência de 15 anos

BACKGROUND: Extra-anatomical bypass, which is an alternative procedure to classical surgery, aims at simplifying a complex procedure such as aortoiliac reconstruction. OBJECTIVES: To analyze long-term outcomes of extra-anatomical bypass of the aortoiliac segment. METHODS: Longitudinal retrospective study including 79 extra-anatomical bypasses of the aortoiliac segment, performed in 75 patients between December 1991 and December 2006. RESULTS: Mean age was 64.2 years, and male gender was predominant (64%). Critical ischemia accounted for most indications for surgery (86.1%); crossover iliofemoral bypass represented 41.8% of all procedures. Mortality, patency and limb salvage rates were 28, 70.3 and 67.6%, respectively, at five years. CONCLUSIONS: Extra-anatomical bypasses should remain as alternative procedures because of their lower patency rates in comparison to anatomic procedures and considerable morbidity and mortality rates. However, they are important procedures when anatomic revascularization cannot be accomplished due to clinical and local limitations. Crossover bypasses demonstrated better patency rates than axillofemoral bypasses, and crossover iliofemoral bypasses showed the best patency rates of all (77.3% at five years).

Arteriosclerose de Monckeberg como causa de isquemia crítica de membros inferiores: relato de caso

Monckebergs arteriosclerosis can be a rare cause of severe lower limb ischemia. We report the case of a patient with critical lower limb ischemia without revascularization conditions progressing to limb amputation. The patient did not present any traditional risk factors associated with atherosclerosis. Histopathological diagnosis showed arteriosclerosis associated with Monckebergs medial calcification.

Tratamento endovascular da síndrome da veia cava superior: relato de caso e revisão da literatura

We report a case of a patient with symptomatic benign superior vena cava syndrome treated by the endovascular technique. The angiographic resonance before angioplasty showed extensive thrombosis of the left brachiocephalic trunk, left subclavian vein and superior vena cava obstruction close to the right brachiocephalic trunk. The patient underwent radical mastectomy 2 years ago with adjuvant chemotherapy and chest radiotherapy. Venous angioplasty and balloon-expandable stenting were performed. Satisfactory result was obtained with immediate relief of symptoms due to recanalization of the right brachiocephalic trunk and superior vena cava. Oral anticoagulation was initiated. The patient is still asymptomatic after 8 months of follow-up. The endovascular treatment is a therapeutic alternative with low morbidity and satisfactory mid-term results that can be offered to patients with superior vena cava syndrome.

Diagnóstico etiológico da trombose venosa profunda de repetição dos membros inferiores

21. Residente de Cirurgia Vascular, Servico de Angiologia e Cirurgia Vas-cular, Irmandade Santa Casa de Misericordia de Porto Alegre, FFFCMPA,Porto Alegre, RS.2. Professor titular, Disciplina de Cirurgia Vascular, Fundacao FaculdadeFederal de Ciencias Medicas de Porto Alegre (FFFCMPA), Porto Alegre,RS. Chefe, Servico de Cirurgia Vascular, Irmandade Santa Casa deMisericordia de Porto Alegre, Porto Alegre, RS.Artigo submetido em 05.03.06, aceito em 13.06.06.

Thoracoabdominal Aortic Aneurysm in a HIV-positive Patient

Advent of antiretroviral therapy has increased survival of patients with human immunodeficiency virus (HIV) infections, with the result that some of these patients now develop degenerative diseases, such as atherosclerotic aneurysms. Degenerative thoracoabdominal aortic aneurysm is rare in HIV patients. In this report, a 63-year-old male patient with HIV submitted to open repair of thoracoabdominal aortic aneurysm. The patient did not suffer any type of complication in the perioperative period and remained well in a 28-month follow-up period. In summary, open repair still remains a good alternative for aortic complex aneurysms even in HIV patients.