Smoking cessation for peripheral arterial disease: systematic review protocol / Cessação do tabagismo para doença arterial periférica: protocolo de revisão sistemática

ABSTRACT Background: peripheral arterial disease has smoking as its main avoidable vascular risk factor. However, most studies do not focus on smoking as the main exposure variable. Objectives: to assess the impact of smoking cessation interventions versus active comparator, placebo or no intervention, on peripheral arterial disease outcomes. Methods: we will use the Cochrane Handbook for Systematic Reviews of Interventions to guide whole this review process. We will consider parallel or cluster-randomised controlled trials (RCTs), quasi-RCTs, and cohort studies. We will search CENTRAL, MEDLINE, Embase, PsycINFO, LILACS and IBECS. We will also conduct a search of ClinicalTrials.gov and the ICTRP for ongoing or unpublished trials. Each research step will involve at least two independent reviewers. We will create a table, using GRADE pro GDT software, reporting the pooled effect estimates for the following outcomes: all-cause mortality, lower limb amputation, adverse events, walking distance, clinical severity, vessel or graft secondary patency, and QoL. Conclusions: we will assess these outcomes according to the five GRADE considerations to assess the certainty of the body of evidence for these outcomes, and to draw conclusions about the certainty of the evidence within the review.

RESUMO Introdução: a doença arterial periférica tem o tabagismo como principal fator de risco vascular evitável. Entretanto, a maioria dos estudos não destaca o tabagismo como principal variável de exposição. Objetivos: avaliar o impacto das intervenções de cessação do tabagismo versus comparador ativo, placebo ou nenhuma intervenção, nos desfechos da doença arterial periférica. Métodos: usaremos o Cochrane Handbook for Systematic Review of Interventions para orientar todo este processo de revisão. Consideraremos ensaios controlados paralelos ou randomizados por cluster (ECRs), quase-ECRs e estudos de coorte. Buscaremos no CENTRAL, MEDLINE, Embase, PsycINFO, LILACS e IBECS. ClinicalTrials.gov e ICTRP serão consultados para ensaios em andamento ou não publicados. Criaremos uma tabela, usando o software GRADE pro GDT, relatando as estimativas de efeito agrupado para os seguintes desfechos: mortalidade por todas as causas, amputação de membro inferior, eventos adversos, distância percorrida, gravidade clínica, permeabilidade secundária do vaso ou enxerto e qualidade de vida. Avaliaremos esses resultados de acordo com as cinco considerações GRADE para avaliar a certeza do corpo de evidências para esses resultados e tirar conclusões sobre a certeza das evidências na revisão.

Vascular complications in 305 severely ill patients with COVID-19: a cohort study

ABSTRACT BACKGROUND: Although an association has been made between coronavirus disease 2019 (COVID-19) and microvascular disease, data on vascular complications (other than venous thromboembolism) are sparse. OBJECTIVE: To investigate the vascular complications in severely ill patients hospitalized with COVID-19 and their association with all-cause mortality. DESIGN AND SETTING: This cohort study was conducted at the Universidade Federal de São Paulo, Brazil. METHODS: All 305 consecutive patients diagnosed with COVID-19 and hospitalized in the intensive care unit (ICU) of a tertiary university hospital from April 2 to July 17, 2021, were included and followed up for 30 days. RESULTS: Of these, 193 (63.3%) were male, and the mean age was 59.9 years (standard deviation = 14.34). The mortality rate was 56.3% (172 patients), and 72 (23.6%) patients developed at least one vascular complication during the follow-up period. Vascular complications were more prevalent in the non-survivors (28.5%) than in the survivors (17.3%) group and included disseminated intravascular coagulation (DIC, 10.8%), deep vein thrombosis (8.2%), acrocyanosis (7.5%), and necrosis of the extremities (2%). DIC (adjusted odds ratio (aOR) 2.30, 95% confidence interval (CI) 1.01-5.24, P = 0.046) and acrocyanosis (aOR 5.21, 95% CI 1.48-18.27, P = 0.009) were significantly more prevalent in the non-survivors than in the survivors group. CONCLUSION: Vascular complications in critically ill COVID-19 patients are common (23.6%) and can be closely related to the mortality rate (56.3%) until 30 days after ICU admission. Macrovascular complications have direct implications for mortality, which is the main outcome of the management of COVID-19. REGISTRATION: RBR-4qjzh7 (https://ensaiosclinicos.gov.br/rg/RBR-4qjzh7).

What do Cochrane systematic reviews say about congenital vascular anomalies and hemangiomas? A narrative review

ABSTRACT BACKGROUND: Congenital vascular anomalies and hemangiomas (CVAH) such as infantile hemangiomas, port-wine stains and brain arteriovenous malformations (AVMs) impair patients' lives and may require treatment if complications occur. However, a great variety of treatments for those conditions exist and the best interventions remain under discussion. OBJECTIVE: To summarize Cochrane systematic review (SR) evidence on treatments for CVAH. DESIGN AND SETTING: Review of SRs conducted in the Division of Vascular and Endovascular Surgery of Universidade Federal de São Paulo, Brazil. METHODS: A broad search was conducted on March 9, 2021, in the Cochrane Database of Systematic Reviews to retrieve any Cochrane SRs that assessed treatments for CVAH. The key characteristics and results of all SRs included were summarized and discussed. RESULTS: A total of three SRs fulfilled the inclusion criteria and were presented as a qualitative synthesis. One SR reported a significant clinical reduction of skin redness by at least 20%, with more pain, among 103 participants with port-wine stains. One SR reported that propranolol improved the likelihood of clearance 13 to 16-fold among 312 children with hemangiomas. One SR reported that the relative risk of death or dependence was 2.53 times greater in the intervention arm than with conservative management, among 218 participants with brain AVMs. CONCLUSION: Cochrane reviews suggest that treatment of port-wine stains with pulsed-dye laser improves redness; propranolol remains the best option for infantile hemangiomas; and conservative management seems to be superior to surgical intervention for treating brain AVMs.

Evidence from Cochrane systematic reviews for effects of antithrombotic drugs for lower-limb revascularization. A narrative review

ABSTRACT BACKGROUND: Peripheral arterial disease (PAD) is characterized by progressive narrowing of the arterial lumen, resulting from atherosclerotic plaques. Treatment for PAD aims to control atherosclerosis and improve blood flow. Use of antiplatelet agents and anticoagulants has played important roles in helping to prevent occlusions and stenosis. OBJECTIVE: To evaluate the evidence from Cochrane systematic reviews regarding the accuracy, effectiveness and safety of use of anticoagulants and antiplatelets in lower-limb revascularization, in patients with peripheral arterial disease. METHODS: Systematic reviews found through searches in the Cochrane Library were included. Two authors evaluated whether the reviews found were in line with the inclusion criteria for this investigation. A qualitative synthesis of their findings was presented. RESULTS: Three systematic Cochrane reviews were included. Patients who underwent prosthetic bypass surgery probably presented greater benefit from use of antiplatelets, and patients who underwent vein revascularization probably presented greater benefit from use of anticoagulants. Patients who received endovascular treatment benefited from both antiplatelet and anticoagulant treatment. However, the reliability of the results found was impaired because at the time when these reviews were published, there was no mandatory assessment using the GRADE criteria. CONCLUSION: Despite the evidence found, it is necessary for these reviews to be updated in order to evaluate the degree of certainty of the results found.

Transcutaneous Electric Nerve Stimulation on ischemic rest pain in inpatients: randomised trial

SUMMARY OBJECTIVE: To investigate the efficacy of a short-term application of Transcutaneous Electric Nerve Stimulation to relieve rest pain in patients with chronic limb-threatening ischemia. METHODS: In patients ³18 years old, with chronic limb-threatening ischemia and rest pain ³3 in the Visual Analogue Scale, without diabetic neuropathy were randomly assigned to 1) Transcutaneous Electric Nerve Stimulation (100 Hz, 200 μs) or 2) sham intervention, both during one or two 20 min treatment sessions. The primary outcome was pain intensity, assessed by the visual analogue scale (0-10 cm) and described by the McGill Pain Questionnaire. We used a t-test for difference of means. RESULTS: A total of 169 patients were assessed, 23 met the study criteria and were randomized. Thirty-four applications were performed in two days: in the 17 Transcutaneous Nerve Stimulation and 17 sham. The within-group analysis indicated a pain decrease in both groups (Transcutaneous Electric Nerve Stimulation, from 7-3.9 cm, p<0.0001, and sham from 5.8-3.2 cm, p<0.0001). No statistically significant difference was verified between-groups (p=0.5). CONCLUSIONS: Both groups showed a decrease in rest pain of 54 and 55%, respectively. However, there was no difference between short-term high-frequency Transcutaneous Electric Nerve Stimulation and sham intervention to relieve ischemic rest pain in chronic limb-threatening ischemia patients.

Evidências de revisões sistemáticas Cochrane para o controle da disseminação da infecção pela COVID-19* / Evidence of revisions systematic Cochrane for the controlling the dissemination of COVID-19 infection

Introdução: A infecção pela COVID-19 tem alta transmissibilidade e várias medidas foram adotadas para controle da disseminação. Objetivo: Identificar e sumarizar as evidências das revisões sistemáticas (RS) Cochrane sobre medidas de controle da disseminação da infecção pela COVID-19. Desenho do estudo: Esta revisão das RS Cochrane foi realizada na Disciplina de Cirurgia Vascular e Endovascular e na Disciplina de Medicina de Urgência e Medicina Baseada em Evidências da Universidade Federal de São Paulo, Brasil. Métodos: Uma busca ampla na Cochrane Database of Systematic Reviews recuperou todas as RS Cochrane que avaliam as evidências diretamente relacionadas às medidas para controle da disseminação da COVID-19. As principais características e resultados de todas as análises incluídas foram sumarizadas e discutidas. Resultados: Três RS Cochrane foram incluídas na síntese qualitativa e versaram sobre medidas populacionais e medidas individuais para controle de disseminação da COVID-19. Conclusão: Evidências de certeza baixa mostram que quarentena de pessoas expostas a casos confirmados ou suspeitos evitou 44%-81% de casos incidentes e 31%-63% de mortes em comparação com nenhuma medida e quanto antes as medidas de quarentena são implementadas, maior a economia de custos. Evidências de confiança alta mostraram que uma comunicação clara sobre as diretrizes de controle e prevenção de infecção foi vital para sua implementação. Evidência de certeza baixa mostrou que as pessoas com um avental longo tiveram menos contaminação

Fisioterapia intra-hospitalar para pacientes com isquemia crítica de membro inferior: consenso de especialistas / Fisioterapia intrahospitalaria para pacientes con isquemia crítica de miembro inferior: consenso de especialistas / Intra-hospital physical therapy for patients with critical lower limb ischaemia: an expert consensus

RESUMO A isquemia crítica de membro inferior (ICMI) gera impacto nos sistemas de saúde, na qualidade de vida e funcionalidade dos indivíduos diagnosticados. Entretanto, há pouca evidência científica que permita fundamentar a intervenção fisioterapêutica para pacientes internados por ICMI. O objetivo desse estudo foi elaborar um consenso de especialistas sobre a fisioterapia intra-hospitalar para pacientes com ICMI. Para tal, foi utilizado o método Delphi. Um painel de especialistas foi formado por 18 fisioterapeutas que representavam 85,7% da equipe de um hospital de referência em cirurgia vascular. Foram consideradas, para o consenso, as respostas com valor mínimo de concordância de 70% e média ou mediana ≥3,1 na escala Likert. Os questionários abordaram itens da avaliação, objetivos e condutas fisioterapêuticas nas fases pré e pós-cirurgia de revascularização. Definiram-se como itens essenciais a avaliação de sintomas, função cognitiva, musculoesquelética e cardiorrespiratória. Controle da dor, redução de edemas, ganho de amplitude de movimento, deambulação e educação em saúde são objetivos no pré-operatório e o ganho de força muscular na fase pós-operatória. Exercícios passivo, assistido, ativo livre e circulatório, incluindo os membros superiores, estão indicados antes e após as cirurgias. Educação em saúde e deambulação com redução de peso em área de lesão plantar são essenciais em todo o período de internação. A eletroanalgesia foi preconizada no pré-operatório e a elevação do membro inferior e exercícios resistidos no pós-operatório.

RESUMEN La isquemia crítica de miembro inferior (ICMI) afecta a los sistemas de salud y la calidad de vida y funcionalidad de los individuos diagnosticados. Sin embargo, hay poca evidencia científica que fundamente la intervención fisioterapéutica para pacientes internados por ICMI. El objetivo de este estudio fue elaborar un consenso de especialistas sobre la fisioterapia intrahospitalaria para pacientes con ICMI. Para ello, se utilizó el método Delphi. Se formó un panel de expertos con 18 fisioterapeutas que representaban el 85,7% del equipo de un hospital de referencia en cirugía vascular. Se consideraron, para el consenso, las respuestas con un valor mínimo de concordancia del 70% y media o mediana ≥3,1 en la escala Likert. Los cuestionarios abordaron ítems de evaluación, objetivos y conductas fisioterapéuticas en las fases pre y poscirugía de revascularización. Se definieron como elementos esenciales la evaluación de síntomas y las funciones cognitiva, musculoesquelética y cardiorrespiratoria. En el preoperatorio, control del dolor, reducción de edemas, ganancia de amplitud de movimiento, deambulación y educación en salud son los objetivos; en la fase posoperatoria, la ganancia de fuerza muscular. Los ejercicios pasivos, asistidos, activos libres y circulatorios, incluidos los miembros superiores, se indican antes y después de las cirugías. La educación en salud y la deambulación con reducción de peso en el área de lesión plantar son esenciales en todo el período de internación. La electroanalgesia fue preconizada en el preoperatorio; y, en el postoperatorio, elevación del miembro inferior y ejercicios resistidos.

ABSTRACT Critical limb ischemia (CLI) is a disease with a great burden for the healthcare system, patient's functionality and quality of life. However, there is little evidence to guide intrahospital physical therapy programs for patients with CLI. Thus, this study aimed to provide an expert consensus on intrahospital physiotherapeutic care for CLI patients. An expert panel was made up with 18 experienced physical therapists, which represented 85.7% of physical therapists from a reference vascular surgery team in a university hospital. The Delphi method was used to produce a consensus, considering a minimum agreement of 70% and a mean or median score in the Likert scale ≥3.1. The questionnaires included items related to assessment, goals and physiotherapeutic interventions prior and after revascularization. A consensus was reached on assessing symptoms, cognitive, articular, musculoskeletal and cardiorespiratory functions. Pain control, edema drainage, range of motion gain, walking incentive and health education are goals in the pre-operatory and the muscular strengthening in postoperatory phase. In both phases there was a consensus on the use of passive, active-assisted and active exercises, including upper limb exercises. Walking and therapeutic education are essential during the hospitalization period with offloading practices in area of plantar ulcer. Electroanalgesia should be used in preoperative phase and resisted exercises and lower limb elevation at postoperatory.

Estenose de carótida extracraniana: revisão baseada em evidências / Extracranial carotid stenosis: evidence based review

RESUMO A doença vascular cerebral extracraniana é uma das mais importantes causas de morte e de incapacidade em todo o mundo e seu tratamento se baseia em estratégias clínica e cirúrgica, sendo que esta última pode ser feita pelas técnicas convencional ou endovascular. O manejo da estenose da bifurcação carotídea visa principalmente a prevenir o acidente vascular cerebral e tem sido objeto de extensa investigação. O papel do tratamento clínico tem sido re-enfatizado, mas a endarterectomia de carótida permanece como o tratamento de primeira linha para pacientes sintomáticos com estenose de 50% a 99% e, para pacientes assintomáticos, com estenose de 60% a 99%. A angioplastia com stent é reservada para pacientes sintomáticos, com estenose de 50% a 99% e com risco elevado para a cirurgia aberta, por motivos anatômicos ou clínicos. Atualmente, o procedimento endovascular não é recomendado para pacientes assintomáticos que tenham condições de serem submetidos ao tratamento cirúrgico convencional. O Brasil apresenta tendência semelhante à de outros países da América do Norte e Europa, observando a manutenção da endarterectomia como a principal indicação para o tratamento da estenose carotídea e reservando o procedimento endovascular para casos em que há contraindicações para a primeira intervenção. Todavia, temos de melhorar os nossos resultados, reduzindo as complicações, notadamente a taxa de mortalidade geral.

ABSTRACT Extracranial cerebrovascular disease is one of the most important causes of death and disability worldwide and its treatment is based on clinical and surgical strategies, the latter being performed by conventional or endovascular techniques. The management of stenosis of the carotid bifurcation is mainly aimed at preventing stroke and has been the subject of extensive investigation. The role of clinical treatment has been re-emphasized, but carotid endarterectomy remains the first-line treatment for symptomatic patients with 50% to 99% stenosis and for asymptomatic patients with 60% to 99% stenosis. Stent angioplasty is reserved for symptomatic patients with stenosis of 50% to 99% and at high risk for open surgery due to anatomical or clinical reasons. Currently, the endovascular procedure is not recommended for asymptomatic patients who are able to undergo conventional surgical treatment. Brazil presents a trend similar to that of other countries in North America and Europe, keeping endarterectomy as the main indication for the treatment of carotid stenosis and reserving the endovascular procedure for cases in which there are contraindications for the first intervention. However, we must improve our results by reducing complications, notably the overall mortality rate.

Spontaneous carotid dissection / Dissecção espontânea de carótida

Summary Carotid dissection is a rare occurrence but it is the main cause of stroke in individuals aged less than 45 years, and can be the etiology in up to 25% of strokes in young adults. We report a case with classic image of ying yang on vascular ultrasound, which was treated according to the best available medical evidence, yielding a favorable outcome.

Resumo A dissecção de carótida é entidade rara, mas é a principal causa de acidentes vasculares cerebrais isquêmicos em menores de 45 anos e pode ser a etiologia de até 25% dos acidentes vasculares cerebrais em adultos jovens. Apresenta-se um caso com imagem clássica de ying yang à ultrassonografia vascular, que foi tratado de acordo com as melhores evidências médicas disponíveis e apresentou boa evolução.

Síndrome de Klippel-Trenaunay-Weber: associação do tratamento operatório à escleroterapia por espuma / Klippel-Trenaunay-Weber syndrome: association of operative treatment with foam sclerotherapy

A Síndrome de Klippel-Trenaunay-Weber representa a associação de hemangiomas planos, ectasias venosas e hipertrofia do segmento corpóreo afetado. Apresenta-se o caso de um paciente de 39 anos, sexo masculino, seguido desde 1993 no serviço da Disciplina de Cirurgia Vascular da Escola Paulista de Medicina (Unifesp), por quadro inicial da síndrome em membro inferior esquerdo. O paciente foi tratado apenas por elastocompressão e medidas gerais. Neste período, ele evoluiu com piora da estase venosa, da hipertrofia óssea e da hiperpigmentação de pele. Na ultrassonografia Doppler colorida venosa dos membros inferiores havia perviedade do sistema venoso profundo, hiperfluxo venoso, insuficiência segmentar de veia safena magna com sinais de tromboflebite e tributárias insuficientes. Indicou-se, para a melhora da estase venosa, ligadura da junção safeno-femoral esquerda e escleroterapia (polidocanol 3 por cento) retrógrada da mesma, com exérese das ectasias venosas. O paciente recebeu alta hospitalar no primeiro dia pós-operatório e atualmente está em acompanhamento ambulatorial com melhora significativa dos sintomas.

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 percent) 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.