Fausto Miranda

Results of surgical treatment compared with ultrasound-guided foam sclerotherapy in patients with varicose veins: a prospective randomised study.

OBJECTIVE This study aims to compare venous clinical severity scores in patients with healed venous ulcers due to varicose veins of the lower limbs (the clinical, etiologic, anatomic, and pathophysiologic data (CEAP) classification: C(5) EpAsPr) treated by saphenous stripping and phlebectomy or by ultrasound-guided foam sclerotherapy. METHOD Sixty patients were included: 29 underwent saphenous stripping and phlebectomy for varices in saphenous tributaries and 27 were treated by ultrasound-guided foam sclerotherapy; four cases were lost to follow-up. The main outcome measure was venous clinical severity scores (pain, oedema, inflammation, hyperpigmentation and lipodermatosclerosis). An ultrasound examination was carried out prior to treatment and 30, 60 and 180 days after the procedure to assess the relative efficacy of the methods in obliterating the saphenous trunk. RESULTS The mean venous clinical severity scores measured before and after 180 days were as follows: Surgery group - pain: before 1.97 standard deviation (SD) 0.19, 180 days 0.72 SD 0.53; oedema: before 1.66 SD 0.48, 180 days 0.55 SD 0.63; inflammation: before 1.55 SD 0.63, 180 days 0.72 SD 0.45. Foam sclerotherapy group - pain: before 1.81 SD 0.40, 180 days 0.56 SD 0.51; oedema: before 1.70 SD 0.47, 180 days 0.48 SD 0.64; inflammation: before 1.67 SD 0.68, after 0.89 SD 0.32. All scores showed statistically significant reductions in both patient groups. The saphenous vein had been obliterated, 180 days after treatment, in 78% of the surgery group, compared with 90% in the foam sclerotherapy group. CONCLUSIONS Ultrasound-guided foam sclerotherapy is a safe and effective option for patients with chronic venous disorders.

Fatores predisponentes para amputação de membro inferior em pacientes diabéticos internados com pés ulcerados no estado de Sergipe

OBJETIVO: Determinar os fatores predisponentes para a amputacao de membros inferiores nos doentes internados com diabetes melito e ulceras nos pes. METODOS: Foram acompanhados os pacientes diabeticos com ulceras nos pes internados no periodo de 6 meses e analisadas as amputacoes nesses doentes em relacao a idade, sexo, amputacao previa, numero de ulceracoes, tempo de diagnostico do diabete, tempo de ulceracao, tempo medio de internacao, gravidade das lesoes, presenca de pulso. RESULTADOS: Verificou-se que 55% (44/80) dos doentes evoluiram para algum tipo de amputacao de membros inferiores; a mediana das idades foi de 61 anos, porem a ocorrencia de amputacao foi significativamente maior na faixa etaria dos 60 aos 90 anos (P = 0,03). Nao se observou uma variacao significativa da mediana do tempo de diagnostico do diabetes, do tempo de ulceracao e do tempo medio de internacao em relacao ao grupo de pacientes que foram amputados. Entretanto, as lesoes mais graves, quando avaliadas pela classificacao de Wagner (P <0,001) e pela ausencia de deteccao dos dois pulsos distais (P <0,001) dos membros inferiores, revelaram-se bastante significativas com relacao ao desfecho de amputacao. CONCLUSAO: Foram considerados fatores predisponentes para a ocorrencia de amputacao nesses doentes a gravidade das lesoes, a ausencia de pulsos e as idades acima de 60 anos.

Hemodynamic improvement in hemorrhagic shock by aortic balloon occlusion and hypertonic saline solutions

The initial treatment of uncontrolled hemorrhage shock from an abdominal source is controversial. The hemodynamic effects of transfemoral diaphragmatic aortic occlusion with a balloon followed by a single bolus of hypertonic saline solutions have been evaluated in 28 dogs. The animals were submitted to pressure-driven hemorrhage for 90 min, according to mean arterial pressure in the abdominal aorta and randomized into four groups, according to the treatment employed at 34 min after hemorrhage. Group 1 dogs (controls) received isotonic NaCl (0.9%, 208 mOsm/l, 4 ml/kg) without aortic occlusion; group 2 underwent aortic occlusion and received isotonic NaCl (0.9%, 308 mOsm/l, 4 ml/kg): group 3 were occluded and received hypertonic NaCl (7.5%, 2400 mOsm/l, 4 ml/kg); group 4 were occluded and received hypertonic sodium acetate (10.5%, 2400 mOsm/l, 4 ml/kg). There were no significant differences between groups at basal measures and also after 30 min of continuous bleeding, when animals presented with severe shock, and significant decreases in mean arterial pressure, cardiac index, systolic index and cardiac filling pressures; the systemic vascular resistance index was increased. Control animals remained in severe shock throughout the experiment and three died. The recovery of mean arterial pressure in aortic-occluded dogs given isotonic NaCl was associated with a marked increase in systemic vascular resistance index, without improvements in cardiac index, systolic index and cardiac filling pressures. In occluded dogs given hypertonic NaCl and NaAc the mean arterial pressure recovery lasted longer, with lower increases in systemic vascular resistance index, while the cardiac index, systolic index and cardiac filling pressures showed a marked albeit transient increase. Injection of hypertonic saline following aortic occlusion produced significantly better hemodynamic profiles and should be seriously considered for the first treatment in severe uncontrolled hemorrhagic shock from an abdominal vascular source.

Prevalência de insuficiência venosa superficial dos membros inferiores em pacientes obesos e não obesos

BACKGROUND: Chronic venous insufficiency of the lower limbs is the most prevalent venous disease. There is an ongoing debate about its etiology and pathophysiology. Several risk factors have been associated with its development, such as age, sex and diet. Obesity is a public health problem and its prevalence has been increasing. Color Doppler ultrasonography is a useful method to evaluate the presence of reflux and/or obstruction of the venous system. OBJECTIVE: To compare the prevalence of superficial venous insufficiency and associated symptoms in obese and non-obese patients. METHODS: After weighing, height measurement and physical examination, patients with body mass index (BMI) 35 kg/m2 and complaints compatible with venous insufficiency were divided into groups I and II, respectively. They underwent color Doppler ultrasonography of the lower limbs, in order to assess the presence or absence of reflux. RESULTS: A total of 311 limbs of 168 patients 25 to 72 years old were examined. For statistical analysis, complaints of varicose veins, pain, swelling, dermatitis, eczema and ulcers, associated or not, were considered. A total of 109 and 104 limbs with varicose veins were obtained in groups I and II, respectively. The prevalence of visible varicose veins (p<0.001) and visible varicose veins with pain (p=0.0118) was higher in group I. Complaints of varicose veins with edema (p<0.001), only edema (p<0.001) and edema with pain (p<0.001) were more prevalent in group II. Data did not present significant statistical difference in the prevalence of varicose veins between groups I and II. CONCLUSION: The prevalence of varicose veins in obese and non-obese individuals is similar ; clinical complaints differ between groups and are consistent and dependent on the presence of venous insufficiency.

Saphenofemoral arteriovenous fistula as hemodialysis access

BackgroundAn upper limb arteriovenous (AV) fistula is the access of choice for haemodialysis (HD). There have been few reports of saphenofemoral AV fistulas (SFAVF) over the last 10-20 years because of previous suggestions of poor patencies and needling difficulties. Here, we describe our clinical experience with SFAVF.MethodsSFAVFs were evaluated using the following variables: immediate results, early and late complications, intraoperative and postoperative complications (up to day 30), efficiency of the fistula after the onset of needling and complications associated to its use.ResultsFifty-six SFAVF fistulas were created in 48 patients. Eight patients had two fistulas: 8 patent (16%), 10 transplanted (20%), 12 deaths (24%), 1 low flow (2%) and 20 thrombosis (39%) (first two months of preparation). One patient had severe hypotension during surgery, which caused thrombosis of the fistula, which was successfully thrombectomised, four thrombosed fistulae were successfully thrombectomised and revised on the first postoperative day. After 59 months of follow-up, primary patency was 44%.ConclusionSFAVF is an adequate alternative for patients without the possibility for other access in the upper limbs, allowing efficient dialysis with good long-term patency with a low complication rate.

Generic Versus Branded Enoxaparin in the Prevention of Venous Thromboembolism Following Major Abdominal Surgery: Report of an Exploratory Clinical Trial

Introduction: Several generic low-molecular-weight heparins (LMWHs) have recently become available worldwide, including the United States. Companies have filed for regulatory approval of generic versions in many countries, based only on compound biochemical characteristics or its immunogenicity. Methods: Prospective study to evaluate the comparative effect of 2 enoxaparins (Sanofi-Aventis branded enoxaparin [SAe] vs eurofarma-enoxaparin [Ee], a generic version) as prophylaxis for venous thromboembolism (VTE) following major abdominal surgery. A total of 200 patients were randomized in a 1:1 ratio either to receive 40 mg of SAe or Ee subcutaneously (sc) once daily (od) postoperatively for 7 to 10 days. Compressive ultrasound was performed on day 10 + 4. Results: No statistically significant differences between the 2 groups were detected. In all, 2 SAe patients presented deep vein thrombosis ([DVT] 2.1%), none of the Ee group. No major bleeding events occurred. Conclusions: This exploratory trial suggests that the generic LMWH is probably as safe and as effective as the branded enoxaparin (Lovenox, Brazil) in the prophylaxis of VTE in this population.

Relationship between the diameter of great saphenous vein and body mass index

OBJETIVO: Este estudo teve o objetivo de comparar o diâmetro da veia safena magna em diferentes niveis dos membros inferiores e o indice de massa corporal dos sujeitos para determinar uma possivel relacao entre esses fatores. METODOS: Cinquenta e dois membros inferiores de 26 voluntarios (seis homens e 20 mulheres) sem registro de doenca venosa cronica, com idades entre 21 e 68 anos, foram avaliados. O indice de massa corporal foi definido antes do eco-Doppler colorido. Os sistemas venosos superficial e profundo e as veias perfurantes foram avaliados de acordo com a literatura. O diâmetro da veia safena magna foi medido atraves de imagem ultra-sonografica longitudinal em sete niveis diferentes. Para a analise estatistica, foram utilizados o teste t de Student para dados pareados e o teste de Spearman. RESULTADOS: A diferenca observada na veia safena no segundo e terceiro niveis, quando comparada aos membros inferiores direito e esquerdo, nao foi considerada significativa, e somente um grupo foi formado para a comparacao com o indice de massa corporal. A correlacao foi considerada estatisticamente irrelevante. CONCLUSAO: Atraves da comparacao dos diâmetros da veia safena magna com o indice de massa corporal dos sujeitos, percebeu-se que a relacao entre esses dois fatores nao e significativa e, portanto, pode-se concluir que individuos altos e magros podem ter veias safenas magnas com diâmetros similares aos de individuos baixos e gordos.

Fístula arteriovenosa safeno-femoral superficial como acesso à hemodiálise: descrição de técnica operatória e experiência clínica inicial

OBJECTIVE: To describe a technique for creating an arteriovenous fistula as an access to hemodialysis, evaluating its technical aspects, efficacy and complications. METHOD: From August 1998 to October 2000, 16 superficial saphenofemoral arteriovenous fistulas were performed in 15 patients. These procedures were used in patients without access options in upper limbs. The surgical technique consisted of an anteriorization and a superficialization of the saphenous vein anastomosed to the superficial femoral artery in the distal portion. The superficial saphenofemoral arteriovenous fistulas were evaluated with regard to puncture, appropriate flow, spontaneous venous pressure, dialysis adequacy and intraoperative complications. RESULTS: There were no intraoperative complications and all the fistulas could be successfully concluded. There was one early death, but the other fistulas were able to the hemodialysis in the 30th postoperative day. Fourteen fistulas were used; in the evolution, three patients were submitted to renal transplant, four presented thrombosis and two presented puncture pseudoaneurysm. CONCLUSION: Superficial saphenofemoral arteriovenous fistulas proved to be a good alternative for patients who do not have other possibilities of vascular access in upper limbs, thus allowing an effective hemodialysis treatment, with a good patency rate at medium term.

Vascular Flow of the Gastric Fundus After Arterial Devascularization: An Experimental Study

BACKGROUND The main complication of transhiatal subtotal esophagectomy with esophagogastric reconstruction is anastomotic leak, which is responsible for a large number of postoperative deaths. It is believed that this complication is due to gastric fundus ischemia caused by the sectioning of the short gastric, left gastric, and left gastro-omental arteries. The literature, however, presents controversies. An experimental study was performed with the aim of evaluating the vascularization of the gastric fundus following sectioning of these arteries. MATERIALS AND METHODS Forty mongrel dogs were distributed into 2 groups: a control group consisting of 15 dogs subjected to surgical simulation and an experimental group consisting of 25 dogs that underwent sectioning of these arteries. Fluorescein testing, gastric mummification, and morphometric image analysis were performed on both groups. RESULTS In comparison with the control group, fluorescein testing on the experimental group demonstrated time-delayed fluorescence in the gastric fundus and partial coloring, (P < 0.001). Image analysis on the mummified gastric samples demonstrated significant reduction in blood vessels in the gastric fundus of the experimental group (P < 0.001). CONCLUSIONS We conclude that sectioning of the short gastric, left gastric, and left gastro-omental arteries causes reduction in blood circulation and in the quantity of blood vessels on the anterior side of the gastric fundus of dogs.

Doença veno-linfática: alterações linfocintilográficas nas úlceras venosas

Contexto: O sistema linfatico tem papel relevante em qualquer tipo de edema periferico. Atualmente, a linfocintilografia e considerada o principal exame para diagnostico da doenca linfatica das extremidades. Embora haja associacao entre edema linfatico e ulcera de estase venosa cronica, a fisiopatologia dessas alteracoes permanece indefinida. Objetivo: Verificar as alteracoes linfocintilograficas qualitativas que ocorrem em pacientes portadores de ulceras de estase dos membros inferiores. Metodos: Quarenta pacientes portadores de ulcera de estase venosa cronica ou cicatriz unilateral foram submetidos a linfocintilografia de ambos os membros inferiores. Foram estudados 25 mulheres e 15 homens, com media de idade de 53,7 anos (28 a 79 anos) e tempo medio de ulcera de 71,5 meses (3 a 240 meses). Foram comparados qualitativamente os parâmetros linfocintilograficos dos membros inferiores, previamente classificados em tres grupos de acordo com a classificacao clinica, etiologica, anatomica e patologica (CEAP): I, membros sem sinais clinicos de doenca venosa ou com telangiectasias e veias reticulares (classes 0 e 1); II, membros inferiores com veias varicosas, edema e/ou alteracoes de pele e subcutâneo (classes 2, 3 e 4); III, membros inferiores com ulcera e/ou cicatriz (classes 5 e 6). Resultados: Quando foi comparada a presenca de alteracoes linfocintilograficas dos membros com ulcera ou cicatriz (grupo III - classes 5 e 6) com as dos membros sem ulcera (grupos I e II - classes 0, 1, 2, 3 e 4), houve diferenca significativa (p < 0,001). Estratificando os membros inferiores de acordo com a classificacao CEAP, tambem foi observada diferenca estatisticamente significante (p < 0,001), sendo as alteracoes linfocintilograficas presentes em 72,5% no grupo III (classes 5 e 6), 30,8% no grupo II (classes 2, 3 e 4) e 7,1% no grupo III (classes 0 e 1). Em relacao aos parâmetros analisados na linfocintilografia, ocorreu diferenca significativa entre o grupo III e os outros grupos quanto a retencao de radiofarmaco, adenomegalia inguinal e refluxo dermico. Nao houve significância nos parâmetros linfonodo popliteo e circulacao colateral. Conclusao: Considerando os resultados, conclui-se que quanto mais grave a estase venosa cronica, maiores serao as alteracoes linfocintilograficas observadas, corroborando a associacao entre doenca venosa e linfatica e entre linfedema secundario e estase venosa cronica.