Ivan Benaduce Casella

Isolated spontaneous dissection of the superior mesenteric artery treated by percutaneous stent placement : Case report

Acute ischemia due to spontaneous dissections of the superior mesenteric artery are uncommon events, with sporadic reports. Therapeutic options include clinical management, direct artery repair, bowel resection, and more recently, endovascular stenting. We present a case of abdominal pain due to superior mesenteric artery spontaneous isolated dissection treated with stent placement and with a favorable 31-month follow-up period.

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.

Outcome Analysis of Infrapopliteal Percutaneous Transluminal Angioplasty and Bypass Graft Surgery With Nonreversed Saphenous Vein for Individuals With Critical Limb Ischemia

Objective: To compare the results of percutaneous transluminal angioplasty (PTA) and bypass graft surgery (BGS) for the treatment of infrapopliteal lesions in individuals presenting with critical limb ischemia (CLI). Method: A total of 48 infrapopliteal PTAs and 50 infrapopliteal BGS were compared retrospectively. All grafts used nonreversed saphenous vein in a single length as a substitute. Results: Secondary patency and limb salvage rates in 24 months for the surgical group were 64.7% and 73.2%, respectively. For PTA group, these values were 63.7% and 68.2%, without differences between groups (log rank; P = .45 and .39, respectively). Bypass graft surgery presented better results of secondary patency (72.9% vs 57.1%) and limb salvage (83.5% vs 53.6%) than PTA for patients with Transatlantic Inter-Society Consensus (TASC) D lesions (P = .04 and P = .01, respectively). Conclusions: Both BGS and PTA provided similar results of patency and limb salvage for individuals with infrapopliteal atherosclerotic disease presenting with CLI. Bypass graft surgery had better results than PTA when TASC D lesions were present.

Inframalleolar Bypass Grafts for Limb Salvage

OBJECTIVE To report our experience of long-term results of inframalleolar bypass. DESIGN Retrospective analysis. MATERIALS AND METHODS We analysed 122 inframalleolar bypasses performed between January 1991 and June 2005 in 116 patients. Most patients were treated for critical ischaemia (97%). The indication for the use of podalic arteries was a lack of tibial arteries with run-off to the foot. The dorsalis pedis was predominantly used for distal anastomoses (62.3%) and the greater saphenous vein (84.4%) as the conduit. The follow-up periods ranged from 1 to 60 months. The endpoints analysed were graft patency, limb salvage, preservation of deambulation and survival rate. RESULTS The cumulative patency was 58.2% at 3 years and 53.4% at 5 years. The best results were achieved with the devalvulated greater saphenous veins. Limb salvage was 70.0% at 3 years and 50.4% at 5 years, with preserved deambulation rates of 57.3% and 47.1%, respectively. There were 36 major and 45 minor amputations. At 3 years, the survival rate was 50.2% and the surgical mortality 13%. Female sex was associated with worse results for cumulative patency and limb salvage (P<0.01). CONCLUSIONS In the long term, inframalleolar bypass is a satisfactory option for limb salvage.

Arm Vein as an Alternative Autogenous Conduit for Infragenicular Bypass in the Treatment of Critical Limb Ischaemia: A 15 Year Experience

OBJECTIVES The value of alternative autogenous venous conduits for treating critical limb ischaemia (CLI) with infragenicular bypass surgery is well established. In this study, the results of using arm veins as alternative conduits for treating CLI over a 15-year period have been evaluated. METHODS This was a retrospective study. Between 1991 and 2005. 120 infragenicular bypasses using arm vein conduits (AVCs) were performed in 120 patients. CLI was the main indication (87.5%) for the procedures. The indications for using arm veins were inadequacy or absence of the ipsilateral greater saphenous vein (GSV). Survival, limb salvage, and patency rates were calculated using the Kaplan-Meier method. RESULTS There was a predominance of male gender (65%), and the group mean age was 68.1 ± 8.3 years. The mean follow-up period was 29.6 ± 26.3 months. The operative mortality (30 days) rate was 7.5%. The main alternative conduit was non-spliced cephalic vein (37.5%). Composite grafts included GSV + AVC (45.2%), AVC + AVC (43.3%) and small saphenous vein + AVC (11.5%). The 5-year primary and secondary patency (SP) rates were 45.2 ± 5.6% and 56.5 ± 5.0%, respectively. The 5-year SP rate was greatest when using non-spliced cephalic vein (65.8 ± 7.6%), but there was no difference in cumulative patency between spliced and non-spliced veins (49.5 ± 8.0% vs. 61.2 ± 6.4%; p = 0.501). The 5-year limb salvage and survival rates were 70.6 ± 5.9% and 59.6 ± 5.8%, respectively. CONCLUSIONS The favourable long term results of secondary patency and limb salvage rates encourage the use of arm veins as alternative conduits for infragenicular bypass surgery.

Endovascular treatment of peripheral arterial injury with covered stents: an experimental study in pigs

OBJECTIVE: To evaluate the feasibility of using endovascular repair to treat penetrating arterial injuries with covered stents. Feasibility was examined according to the circumferential extent of the injury. INTRODUCTION: Surgical trauma often increases the risk of major morbidity and mortality associated with vascular injury, and endovascular repair has many advantages in such situations. METHODS: Twenty white male domestic pigs weighing 28-38 kg with controlled vascular injuries were divided into four equal groups according to the circumferential extent of their vascular lesion (i.e., no lesion, lesion <50%, lesion >50%, and complete lesion). The left common carotid artery was dissected with proximal and distal control, and this procedure was followed by controlled sectioning of the arterial wall. Local manual compression was applied for 10 min and was followed by endovascular repair with the placement of a 5×50 mm VIABHANTM covered stent using the femoral approach. We also monitored additional variables, such as the duration of the procedures (the mean was 56.3±19.1 min), ultrasound parameters (e.g., maximum arterial diameter, peak systolic and diastolic velocity, and resistance index), arteriography findings, and fluctuations in vital signs (e.g., cardiac output, arterial pressure, and central venous pressure). RESULTS: The experimental procedure was found to be feasible and reproducible. Repairs were successful in all animals in the control (no lesion) and <50% lesion groups. Success was also achieved in four out of five pigs in the >50% group and in one pig in the complete lesion group. DISCUSSION: The endovascular repair of an arterial injury is possible, but success depends on the circumferential extent of the arterial lesion. The present experimental model, which involved endovascular techniques, highlighted important factors that must be considered in future studies involving similar animals and materials.

A Prospective Randomized Study Comparing Polidocanol Foam Sclerotherapy with Surgical Treatment of Patients with Primary Chronic Venous Insufficiency and Ulcer

BACKGROUND To compare polidocanol foam sclerotherapy with surgical treatment of patients with primary chronic venous insufficiency and active ulcer treated at a single vascular center. METHODS Fifty-eight limbs of 56 patients with active ulcers were prospectively randomized to undergo either surgical treatment or foam sclerotherapy. Patients completed the Aberdeen Varicose Veins Questionnaire (AVVQ), the Venous Clinical Severity Score (VCSS), and Venous Disability Score (VDS). The follow-up was 502 ± 220 days. RESULTS The ulcer healed in 100% and 91.3% of patients treated with surgery or foam sclerotherapy, respectively (P > 0.05). There were no significant differences in AVVQ, VCSS, and VDS between the 2 groups after the procedures (P = 0.45, 0.58, and 0.66, respectively; Mann-Whitney U test). Complications occurred in 14.2% and 13.0% in the surgical and foam sclerotherapy groups, respectively. CONCLUSIONS Surgical treatment and foam sclerotherapy achieved high rates of ulcer healing, without a statistically significant difference. Both treatments led to significant improvements in VCSS, VDS, AVVQ scores, demonstrating improvements in clinical outcomes and quality of life.

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.

Obesity Is a Risk Factor for Significant Carotid Atherosclerosis in Patients Aged 39 to 55 Years

We compared the prevalence of risk factors between young and old individuals with significant carotid atherosclerosis. We retrospectively reviewed the records of patients aged 39 to 55 years (group I) and aged ≥60 years (group II) with significant atherosclerotic stenosis at the carotid bifurcation. Group I patients had significantly higher values for the following factors: weight, height, body mass index, diastolic pressure, prevalence of current smoking, total and low-density lipoprotein cholesterol and significant lower values for systolic pressure, creatinine, and prevalence of coronary artery disease. Group I patients were more symptomatic and showed higher rates of carotid occlusion and near occlusion. Atherosclerosis of the carotid bifurcation was more aggressive in the younger group, with a higher rate of occlusion and near occlusion. Obesity and smoking were significant risk factors for young patients in this sample.

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.