Ricardo Jayme Procópio

Embolia balística venosa retrógrada transtorácica: relato de caso e revisão da literatura

Bullet embolism is a rare event when providing care to traumatized patients. These cases usually present with few symptoms or are asymptomatic, and treatment is controversial, in spite of the evolution observed. The endovascular approach has stood out as a treatment modality for this type of embolism with low morbidity and mortality rates. This article reports the case of a 30-year-old male patient victim of gunshot thorax injury with multiple entrance signs who was successfully submitted to bullet removal by endovascular technique after failed attempt by thoracotomy.

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.

Diabetic foot ulcer carries high amputation and mortality rates, particularly in the presence of advanced age, peripheral artery disease and anemia

INTRODUCTION Foot ulcer is also a clinical marker for limb amputation and for death in diabetic patients. The purpose of this study was to determine amputation and mortality rates and its associated factors in patients with diabetic foot ulcerations in a tertiary hospital in Brazil. METHODS Retrospective medical records from 654 diabetic foot patients were reviewed. The risk factors were determined using the conditional logistic regression model analysis. RESULTS The mean patient age was 63.1 years (SD 12.20). Peripheral arterial disease was present in 160 patients (24.5%). Major amputations were performed in 135 (21%). The in-hospital mortality rate was 12% and the mortality rate of the amputees was 22.2%. The lowest hemoglobin level, the median value was 9.50g/dL, (4.0-17.0). Anemia was detected in 89.6% of patients submitted to amputation and in 82,1% of those who died. Hemoglobin <11g/dL was the most significant risk factor for major amputation (odds ratio 5.57, p<0.0001). The presence of peripheral arterial disease and old age were also a risk for major amputation (odds ratio 1.84, p=0.007 and 1.02, p=0.028, respectively). Factors associated with increased risk for death were hemoglobin <11g/dL (odds ratio 4.04, p<0.001), major amputation (1.79, p=0.03) and old age (1.05, p<0,001). CONCLUSIONS Diabetic foot ulcer is associated with high amputation and mortality rates. Old age, peripheral arterial disease and low hemoglobin level are risk factor for major amputation. Old age, major amputation and low hemoglobin level are risk factors for death.

Incidence of deep vein thrombosis and quality of venous thromboembolism prophylaxis

OBJECTIVE to determine the incidence of deep vein thrombosis and prophylaxis quality in hospitalized patients undergoing vascular and orthopedic surgical procedures. METHODS we evaluated 296 patients, whose incidence of deep venous thrombosis was studied by vascular ultrasonography. Risk factors for venous thrombosis were stratified according the Caprini model. To assess the quality of prophylaxis we compared the adopted measures with the prophylaxis guidelines of the American College of Chest Physicians. RESULTS the overall incidence of deep venous thrombosis was 7.5%. As for the risk groups, 10.8% were considered low risk, 14.9%moderate risk, 24.3% high risk and 50.5% very high risk. Prophylaxis of deep venous thrombosis was correct in 57.7%. In groups of high and very high risk, adequate prophylaxis rates were 72.2% and 71.6%, respectively. Excessive use of chemoprophylaxis was seen in 68.7% and 61.4% in the low and moderate-risk groups, respectively. CONCLUSION although most patients are deemed to be at high and very high risk for deep vein thrombosis, deficiency in the application of prophylaxis persists in medical practice.

Aneurisma de artéria ilíaca interna roto: relato de caso

Isolated internal iliac artery aneurysms are rare. They affect 0.1% of the population, and account for 1% of aortoiliac aneurysms. Patients are mostly asymptomatic, yet they can have abdominal pain, pulsatile mass in the hypogastrium or iliac fossa, or urinary, gastrointestinal or neurological compressive symptoms. Such aneurysms are likely to course with an acute abdomen, especially when ruptured. Early diagnosis of isolated internal iliac artery aneurysms is difficult, as they are more easily detected when larger or ruptured, which significantly raises their morbidity and mortality rate and determines a poor prognosis. Therefore, they are a therapeutic challenge. Surgical ligation has been the most common treatment; however, the endovascular approach has presented good outcomes, even in the event of ruptured aneurysms. A case of ruptured isolated iliac artery aneurysm diagnosed during a laparotomy (acute abdomen approach) is reported.

Vascular Surgery Training Paradigms in Asia, Europe, South America, the United Kingdom, and the United States

Around the world there are variations in the training pathway for vascular surgery. The time from high school graduation to the completion of vascular surgery training ranges from 11 to 15 years, and possibly more depending on research experience, other graduate degrees, or extracurricular experiences. This chapter gives a sampling of the similarities and differences across Asia, Europe, South America, the United Kingdom (UK) and the United States (US).

Thoracic Aortic Aneurysms in Brazil

Thoracic aortic aneurysms (TAA) are true aneurysms located at the segments of the thoracic aorta [1, 2]. Ascending aortic aneurysms arise anywhere from the aortic valve to the innominate artery and affects 60 % of these patients. Aortic arch aneurysms, seen in 10 % of the patients, include any thoracic aneurysm that involves the brachiocephalic vessels. Descending aortic aneurysms are those distal to the left subclavian artery and are present in 40 % of these. Thoracoabdominal aneurysms, accounting for 10 %, involve any extension of the thoracic aorta, including the visceral segment. These categories help to stratify the approach to management.

Peripheral Artery Disease

Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis that leads to reduction of limb’s blood supply, leading to acute or critical ischemia. In the United States, this condition affects 4.3 % of the general population. In about 90 % of the chronic cases, it is caused by atherosclerosis, and it is an important marker of cardiovascular risk and death. The remaining cases are caused by a varied group of pathologies, such as arteritis and neuropathies. Peripheral arterial disease’s risk factors are advanced age, hypertension, diabetes mellitus, smoking, and hyperlipidemia. Its most common symptom is intermittent claudication, but the patient may also be asymptomatic (the largest group of patients), experiencing pain at rest or ulceration. The gold standard test to determine the presence of peripheral vascular disease is calculation of the ankle-brachial index. Treatment is divided into lifestyle, medical, and surgical revascularization therapies, and it is aimed at pain relief, healing of ulcerations, prevention of limb loss, independent walking maintenance, risk factors control, and survival increasing.

Acute Limb Ischemia

Acute ischemia is the sudden reduction of limb perfusion due to acute interruption of blood flow, endangering its viability. It may be secondary to an embolic event or arterial thrombosis, each with its own distinct characteristics and prognosis. The symptoms are known as the six P’s: Pain, Pallor, Paresthesia, Paralysis, Pulseless, and Poikilothermia. Time of ischemia defines the prognosis. Treatment requires an expert since it involves urgent revascularization surgery in many cases. The degree and time of ischemia helps determine the best choice of treatment.

Hybrid Treatment with Complete Transposition of Supra-Aortic Trunks

Objective The disease of the aortic arch is traditionally approached by open surgical repair requiring cardiopulmonary bypass and circulatory arrest. This study performed a retrospective analysis comparing outcomes through primary hybrid patients submitted to aortic arch surgery without cardiopulmonary bypass with patients submitted to conventional open surgery. Methods 25 patients submitted to the aortic arch surgery were selected in the period 2003-2012 at the Madre Teresa Hospital in the city of Belo Horizonte, Brazil; 13 of these underwent hybrid technique without cardiopulmonary bypass and 12 underwent conventional open surgery. Results The mortality rate for the hybrid group was 23% and for the conventional surgery group was 17% (P=0.248). The postoperative complication rate was also similar in both groups, with no significant difference. Conclusion Both techniques proved to be similar in mortality and morbidity. However, due to the small sample, more analytical studies with larger samples and long-term follow-up are needed to clarify this issue.