Newton de Barros

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.

A variabilidade hemodinâmica venosa detectada pelos parâmetros da pletismografia a ar nas classes clínicas da classificação CEAP

BACKGROUND: The hemodynamic variability of air plethysmography is known in the literature, but the clinical significance of this event has not been investigated yet, and there may be some unexplored clinical meaning. There is known superpositioning of CEAP clinical classes (C0-C6) and even in lower limbs of the same clinical classes. OBJECTIVE: To evaluate hemodynamic variability of air plethysmography parameters in CEAP clinical classes. METHODS: This retrospective study compares lower limb varicose disease between C0 and C6 CEAP clinical classes with venous hemodynamic parameters obtained by air plethysmography. Data were tabled and analyzed according to their clinical classes by Kruskal-Wallys and Barllet variance tests. RESULTS: A total of 310 examinations were performed in 230 patients, aged between 19-81 years (mean = 46.2 years). Venous filling index and functional venous volume increased hemodynamic variability when compared with CEAP C0. This was demonstrated by the variability coefficient, which was 28.12% for venous filling index in C0 and higher than 57% between clinical classes C2 and C6. Ejection fraction and residual venous fraction had no increase in variability when compared with CEAP C0. CONCLUSION: Venous filling index is the best parameter for assessment and screening patients with chronic venous insufficiency, but has great variability in C2 to C6 CEAP clinical classes.

Síndrome de Klippel-Trenaunay-Weber: associação do tratamento operatório à escleroterapia por espuma

The Klippel-Trenaunay-Weber Syndrome is the association of hemangioma, venous ectasia, and hypertrophy of the affected body segment. We report the case of a 39-year-old male followed-up since 1993 due to onset of symptoms in the left lower limb. He was treated only with the use of elastic stockings and general measures. Over the years, he had worsening of venous stasis, of bone hypertrophy, and of skin hyperpigmentation. Color-coded Doppler ultrasonography of the lower limbs showed patency of the deep venous system, venous overflow, segmentar insufficiency of the greater saphenous vein with signs of thrombophlebitis, and insufficient tributary veins. In order to improve venous stasis, ligation of the left sapheno-femoral junction and retrograde foam sclerotherapy (polidocanol 3%) with resection of tributary veins were performed. The patient was discharged in the first postoperative day and has been followed as an outpatient, presenting significant improvement of the symptoms.

Peroneal nerve palsy due to compartment syndrome after facial plastic surgery

A 25-year-old white man, right after bilateral rhytidoplasty, presented with agitation, necessitating use of haloperidol. Some hours after, he developed severe pain in his legs and a diagnosis of neuroleptic malignant syndrome (NMS) was considered. Even with treatment for NMS he still complained of pain. A diagnosis of lower limb compartment syndrome (CS) was done only 12 hours after the initial event, being submitted to fasciotomy in both legs, disclosing very pale muscles, due to previous ischemia. This syndrome was not explained only by facial surgery, his position and duration of the procedure. It can be explained by a sequence of events. He had a history of pain in his legs during physical exercises, usually seen in chronic compartment syndrome. He used to take anabolizant and venlafaxine, not previously related, and the agitation could be related to serotoninergic syndrome caused by interaction between venlafaxine and haloperidol. Rhabdomyolysis could lead to oedema and ischemia in both anterior leg compartment. This report highlights the importance of early diagnosis of compartment syndrome, otherwise, even after fasciotomy, a permanent disability secondary to peripheral nerve compression could occur.

Pseudoaneurisma artéria femoral pós-angioplastia percutânea de artéria renal

Universidade Federal de Sao Paulo (UNIFESP) Escola Paulista de Medicina Disciplina de Cirurgia Vascular