Jose O Leite

Treatment of Hostile Proximal Necks During Endovascular Aneurysm Repair.

Endovascular aneurysm repair (EVAR) is a therapy that continues to evolve rapidly as advances in technology are incorporated into new generations of devices and surgical practice. Although EVAR has emerged as a safe and effective treatment for patients with favorable anatomy, treatment of patients with unfavorable anatomy remains controversial and is still an off-label indication for endovascular treatment with some current stent-grafts. The proximal neck of the aneurysm remains the most hostile anatomic barrier to successful endovascular repair with long-term durability. Open surgery for unfavorable necks is still considered the gold standard treatment in contemporary practice, despite the increased mortality and morbidity attributed to suprarenal cross-clamping, particularly in high-risk patients. Evolving technology may overcome the obstacles preventing endovascular treatment of unfavorable proximal neck anatomy; current approaches include purely endovascular as well as hybrid approaches, and generally include strategies that either extend the length of the short neck, move the proximal neck more proximally, or keep the short neck intact. These approaches include the use of debranching techniques, banding, chimneys, fenestrated and branched devices, filling the sac with endobags, endoanchors, and other novel devices. These newer-generation devices appear to have promising short- and midterm results. However, lack of good evidence of efficacy with long-term results for these newer approaches still precludes wide dissemination of endovascular solutions for the hostile proximal neck.

General outcomes and risk factors for minor and major amputations in Brazil

Objectives Major and minor amputations are associated with significant rates of mortality. However, little is known about the impact of unplanned redo-amputation during the same hospitalization on outcomes. The objectives of this study were to identify the risk factors associated with in-hospital mortality after both major and minor amputations as well as the results of unplanned redo-amputation on outcome. Methods Retrospective study of 342 consecutive patients who were treated with lower extremity amputation in Brazil between January 2013 and October 2014. Results The in-hospital mortality rate was higher in major compared to minor amputation (25.6% vs. 4.1%; p < 0.0001). Whereas chronic kidney disease, chronic obstructive pulmonary disease, and planned staged amputation predicted in-hospital mortality after major amputation, age, and congestive heart failure predicted mortality after minor amputation. The white blood cell count predicted in-hospital mortality following both major and minor amputation. However, postoperative infection predicted in-hospital mortality only following major amputation. Conclusions In-hospital mortality was high after major amputations. Unplanned redo-amputation was not a predictor of in-hospital mortality after major or minor amputation. Planned staged amputation was associated with reduced survival after major but not minor amputation. Postoperative infection predicted mortality after major amputation. Systemic diseases and postoperative white blood cell were associated with in-hospital mortality. This study suggests a possible link between a pro-inflammatory state and increased in-hospital mortality following amputation.

Evidências para o uso da avaliação nutricional subjetiva global nos pacientes com doença arterial periférica

A desnutricao e uma doenca extremamente prevalente em pacientes internados, chegando a acometer 50% deles, 47% dos pacientes cirurgicos e entre 39 e 73% dos portadores de doenca arterial periferica, com grande impacto na morbimortalidade desses pacientes. A desnutricao possui grande relevância no desfecho clinico desses pacientes durante a internacao, estando associada a maior incidencia de infeccoes, demora na cicatrizacao das feridas, diminuicao do status de deambulacao, maior tempo de internacao e mortalidade. Entretanto, o diagnostico de desnutricao ou risco nutricional desses pacientes tem sido um desafio. A avaliacao nutricional subjetiva global revelou-se, ate o momento, o padrao ouro como metodo de triagem de pacientes cirurgicos internados devido a sua praticidade e acuracia. O objetivo deste trabalho e revisar metodos utilizados na avaliacao do estado nutricional e da triagem nutricional de pacientes internados e caracterizar a importância dessa avaliacao nos desfechos clinicos dos pacientes com arteriopatias.

Incidence of deep venous thrombosis and stratification of risk groups in a university hospital vascular surgery unit

CONTEXTO: Ha lacuna de conhecimento sobre a real incidencia de trombose venosa profunda nos pacientes submetidos a procedimentos cirurgicos vasculares no Brasil. A atual pesquisa pretende corroborar a implementacao de um sistema de vigilância e controle sobre a qualidade de profilaxia de tromboembolismo venoso em nosso meio. As investigacoes, em cada instituicao, permitiriam revelar a incidencia de trombose venosa profunda e a identificacao dos grupos de risco, a fim de assumir medidas para obter profilaxia e terapeutica adequadas contra essa afeccao.OBJETIVO: Estudar a incidencia de trombose venosa profunda e estratificar os grupos de risco em pacientes internados, submetidos a procedimentos cirurgicos vasculares nao venosos.METODO: Estudo observacional transversal, que avaliou 202 pacientes da Clinica de Cirurgia Vascular de um hospital universitario, entre marco de 2011 e julho de 2012. A incidencia de trombose venosa profunda foi determinada por meio de exame ultrassonografico vascular, realizado em todos os pacientes. Os fatores de riscos de cada paciente foram estratificados de acordo com a escala Caprini.RESULTADOS: A media de incidencia de trombose venosa profunda na Cirurgia Vascular foi de 8,5%. Em relacao aos grupos de risco para tromboembolismo venoso, 8,4% foram considerados de baixo risco, 17,3% de moderado risco, 29,7% de alto risco e 44,6% de altissimo risco.CONCLUSAO: A incidencia de trombose venosa profunda na Cirurgia Vascular foi de 8,5%, semelhante a registrada na literatura internacional. A maior parte dos pacientes cirurgicos vasculares e estratificada em alto e altissimo risco para trombose venosa profunda.