Pedro Puech Leão

Strength training increases walking tolerance in intermittent claudication patients: Randomized trial

OBJECTIVE To analyze the effects of strength training (ST) in walking capacity in patients with intermittent claudication (IC) compared with walking training (WT) effects. METHODS Thirty patients with IC were randomized into ST and WT. Both groups trained twice a week for 12 weeks at the same rate of perceived exertion. ST consisted of three sets of 10 repetitions of whole body exercises. WT consisted of 15 bouts of 2-minute walking. Before and after the training program walking capacity, peak VO(2), VO(2) at the first stage of treadmill test, ankle brachial index, ischemic window, and knee extension strength were measured. RESULTS ST improved initial claudication distance (358 +/- 224 vs 504 +/- 276 meters; P < .01), total walking distance (618 +/- 282 to 775 +/- 334 meters; P < .01), VO(2) at the first stage of treadmill test (9.7 +/- 2.6 vs 8.1 +/- 1.7 mL.kg(-1).minute; P < .01), ischemic window (0.81 +/- 1.16 vs 0.43 +/- 0.47 mm Hg minute meters(-1); P = .04), and knee extension strength (19 +/- 9 vs 21 +/- 8 kg and 21 +/- 9 vs 23 +/- 9; P < .01). Strength increases correlated with the increase in initial claudication distance (r = 0.64; P = .01) and with the decrease in VO(2) measured at the first stage of the treadmill test (r = -0.52; P = .04 and r = -0.55; P = .03). Adaptations following ST were similar to the ones observed after WT; however, patients reported lower pain during ST than WT (P < .01). CONCLUSION ST improves functional limitation similarly to WT but it produces lower pain, suggesting that this type of exercise could be useful and should be considered in patients with IC.

Impact of cigarette smoking on papaverine-induced erection

Owing to the vasoconstrictive effect of nicotine, smoking may potentially interfere in the results of the drug-induced erection test for papaverine hydrochloride. To investigate the effect of smoking on this test, 12 patients between 22 and 65 years old underwent the following protocol: phase 1--intracavernous injection of 100 mg. papaverine hydrochloride with measurement of intracavernous pressure by puncture with a 19 caliber butterfly needle attached to an aneroid manometer and phase 2--1 week after the initial test the procedure was repeated after the patient smoked 2 cigarettes. In phase 1 all men obtained a full erection, compared to only 4 in phase 2. The average intracavernous pressures were 85.83 and 53.50 mm. Hg, respectively, in phases 1 and 2 (p less than 0.01). We conclude that cigarette smoking, probably through nicotine, interferes with the drug-induced erection test, which might explain some false negative results.

Simpatectomia cervicotoracica por videotoracoscopia: experiência inicial

O objetivo do presente trabalho e avaliar os resultados iniciais obtidos com a simpatectomia cervicotoracica videotoracoscopica. De outubro de 1995 a outubro de 1997 foram realizados 24 procedimentos em 14 pacientes: dez homens e quatro mulheres, com idades que variaram de 16 a 56 anos, media de 30 anos. Indicacoes para a operacao foram: hiperidrose palmar em dez pacientes, isquemia de mao em tres e causalgia em um. Nos casos de hiperidrose, a resseccao da cadeia simpatica incluiu T2 e T3. Nos portadores de isquemia e causalgia tambem o gânglio estrelado foi ressecado. Vinte e tres das 24 extremidades mostraram excelente resposta imediata a simpatectomia. Somente uma extremidade de paciente com hiperidrose permaneceu inalterada devido a procedimento incompleto, tendo sido desnervada pela mesma tecnica em reoperacao posterior, com bom resultado. Pneumotorax residual pos-operatorio ocorreu em uma paciente com resolucao espontânea. Treze pacientes tiveram seguimento que variou de dois a 18 meses, com media de 11 meses. Nao houve mortalidade nessa serie, e a principal complicacao tardia observada nos pacientes operados por hiperidrose foi a hiperidrose compensatoria, que ocorreu, em grau variado, nos nove pacientes com seguimento, sendo que em 30% deles esta manifestacao foi significativa. Concluimos tratar-se de procedimento simples, seguro, eficiente e de melhor aceitacao por parte dos pacientes do que a operacao convencional.

Can contrast-enhanced ultrasound with second-generation contrast agents replace computed tomography angiography for distinguishing between occlusion and pseudo-occlusion of the internal carotid artery?

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of contrast-enhanced ultrasound with a second-generation contrast agent in distinguishing between occlusion and pseudo-occlusion of the cervical internal carotid artery, comparing it with that of conventional Doppler ultrasound and the gold standard, computed tomography angiography. METHOD: Between June 2006 and June 2012, we screened 72 symptomatic vascular surgery outpatients at a public hospital. Among those patients, 78 cervical internal carotid arteries were previously classified as occluded by Doppler ultrasound (without contrast). The patients were examined again with Doppler ultrasound, as well as with contrast-enhanced ultrasound and computed tomography angiography. The diagnosis was based on the presence or absence of flow. RESULTS: Among the 78 cervical internal carotid arteries identified as occluded by Doppler ultrasound, occlusion was confirmed by computed tomography angiography in only 57 (73.1%), compared with 59 (77.5%) for which occlusion was confirmed by contrast-enhanced ultrasound (p>0.5 vs. computed tomography angiography). Comparing contrast-enhanced ultrasound with Doppler ultrasound, we found that the proportion of cervical internal carotid arteries classified as occluded was 24.4% higher when the latter was used (p<0.001). CONCLUSIONS: We conclude that, in making the differential diagnosis between occlusion and pseudo-occlusion of the cervical internal carotid artery, contrast-enhanced ultrasound with a second-generation contrast agent is significantly more effective than conventional Doppler ultrasound and is equally as effective as the gold standard (computed tomography angiography). Our findings suggest that contrast-enhanced ultrasound could replace computed tomography angiography in this regard.

Peroneal artery approach for angioplasty of the superficial femoral artery: a case report.

The authors report the implantation of a Palmaz stent in the superficial femoral artery using an approach not previously described, the peroneal artery. A 64-year-old man was admitted with extensive necrosis of the right foot. Physical examination showed a normal right femoral pulse but absence of popliteal and tibial pulses. Arteriography showed a superficial femoral artery with critical stenoses but a normal profunda artery. A classic below-knee amputation was performed. During the procedure, the muscular blood flow was considered insufficient, by clinical experience, to achieve limb healing at this level, and so the surgeon chose to perform an angioplasty of the superficial femoral artery lesion, utilizing an access through the leg arteries. After introducing the guidewire through the peroneal artery, the surgeon successfully dilated the lesion and implanted a Palmaz stent. Afterward, the popliteal pulse became palpable in physical examination and improved the skin and muscular aspect in this level. The surgery was finished with a closed stump. The surgery healed satisfactorily, without any complications, and the patient had a satisfactory follow-up, with ambulatory rehabilitation, and recovery of walking capacity with a leg prosthesis. The peroneal approach gave satisfactory results and should be considered in clinical situations like this.

Endovascular repair of ruptured aortic aneurysms: do not let the patient die while you are planning

Before endovascular grafting for aneurysms was possible, surgeons got used to fearing intra-hospital rupture of aneurysms, which is not rare. The standard procedure used to be as follows: patients with the classical syndrome – hypovolemia + abdominal pulsatile mass – shall be taken to the operating room at once. If abdominal palpation was difficult, an ultrasound performed at the patient’s bed could confirm diagnosis. Mobilization of the patient for computed tomography (CT) scan or nuclear magnetic resonance (NMR) could precipitate rupture and death; thus, mobilization was generally thought to be a dangerous action.

Quality of bevacizumab (Avastin®) repacked in single-use glass vials for intravitreal administration

Purpose: Avastin® (bevacizumab) is an anti-vascular endothelial growth factor (VEGF) monoclonal antibody given as an off-label drug by intravitreal administration for treatment of ocular diseases. The drugs clinical application and its cost-benefit profile has generated demand for its division into single-use vials to meet the low volume and low-cost doses necessary for intraocular administration. However, the safety of compounding the drug in single-use vials is still under discussion. In this study, the stability and efficacy of Avastin® repacked in individual single-use glass vials and glass ampoules by external compounding pharmacies were evaluated. Methods: Polyacrylamide gel electrophoresis (PAGE), size-exclusion chromatography (SEC), dynamic light scattering (DLS), and turbidimetry were selected to detect the formation of aggregates of various sizes. Changes in bevacizumab biological efficacy were investigated by using an enzyme-linked immunosorbent assay (ELISA). Results: Repacked and reference bevacizumab showed similar results when analyzed by PAGE. By SEC, a slight increase in high molecular weight aggregates and a reduction in bevacizumab monomers were observed in the products of the three compounding pharmacies relative to those in the reference bevacizumab. A comparison of repacked and reference SEC chromatograms showed that the mean monomer loss was ≤1% for all compounding pharmacies. Protein aggregates in the nanometer- and micrometer-size ranges were not detected by DLS and turbidimetry. In the efficacy assay, the biological function of repacked bevacizumab was preserved, with <3% loss of VEGF binding capacity relative to that of the reference. Conclusion: The results showed that bevacizumab remained stable after compounding in ampoules and single-use glass vials; no significant aggregation, fragmentation, or loss of biological activity was observed.

Classic Citations: Direct Arterial Anastomosis on Corpora Cavernosal Penis in the Therapy of Erectile Impotence. V. Michal, R. Kramar, J. Pospichal, and L. Hejhal

I n 1973, Michal et al. published the first article [1] proposing corpus cavernosum revascularization through a direct arterial anastomosis to the cavernous body for the treatment of “chronic erective impotence.” The article was published in Czech and presented two experimental series and a case report of a patient with a history of 6 years of erectile dysfunction. In the experimental series, the authors had performed a direct anastomosis with the popliteal artery and femoralis superficialis artery to the corpus spongiosum and corpus cavernosum of dogs. The anastomosis to the corpus spongiosum had remained patent for more than 2 months and those to the corpus cavernosum for more than 3 weeks. The authors considered that the anastomosis to the cavernous body occluded because there was a disproportion of the flow between incoming arteries and the drainage of the corpus cavernosum; they stated that “there was a high-pressure system with limited possibility of drainage.” However, Michal et al. presented a patient who had been submitted to an end-to-side anastomosis between the epigastric artery and the corpus cavernosum, at the level of the pubic symphisis. They reported that the patient had resumed frequent spontaneous erections and that this result justified the use of this intervention in the treatment of “chronic impotence.” This work is one of the landmark articles in modern sexual medicine. Sidney Glina, MD Chair, Classic Citation

Classificação angiográfica na revascularização do membro inferior isquêmico: pode a angiografia definir a resistência do leito receptor do enxerto?

BACKGROUND: Angiography is often used as the only preoperative method to define the therapeutic approach for ischemic lower limb revascularization, either by transluminal angioplasty or surgery. Today its use is still controversial. OBJECTIVE: To compare a simple method of angiographic classification with hemodynamic preoperative and intraoperative studies of the ischemic arterial bed in order to verify its efficacy in defining arterial bed resistance. METHODS: We analyzed 68 cases of surgical revascularization of ischemic lower limbs performed from July 1999 to July 2004 at the Division of Vascular Surgery of Instituto Dante Pazzanese de Cardiologia. The characteristics of the graft recipient arterial runoff were studied and compared using the method of preoperative angiographic classification proposed by the authors, preoperative hemodynamic analysis by color duplex scanning, and intraoperative direct measurements of flow, pressure and resistance. RESULTS: Positive rates for Spearman correlation (p < 0.05) were observed between the preoperative angiographic classification proposed in this study and the preoperative ultrasound hemodynamic measurements of blood flow volume (p = 0.035) and direct intraoperative measurements of flow (p = 0.006), pressure (p = 0.037) and resistance (p = 0.006). CONCLUSION: The preoperative method of angiographic classification proposed can assess the resistance of the arterial bed to be revascularized and help to define the approach and prognosis of the revascularization of ischemic lower limbs.