Shared decision-making and specific informed consent in patients with aortic aneurysms

ABSTRACT Objective To analyze the refusal rate of elective aortic aneurysm surgery in asymptomatic patients after the presentation of a detailed informed consent form followed by a meeting where patient and their families can analyze each item. Methods We conducted a retrospective analysis of 49 patients who had aneurysms and were offered surgical treatment between June 2017 and February 2019. The patients were divided into two groups: the Rejected Surgery Group, which was composed of patients who refused the proposed surgical treatment, and the Accepted Surgery Group, comprising patients who accepted the proposed surgeries and subsequently underwent them. Results Of the 49 patients, 13 (26.5%) refused surgery after reading the informed consent and attending the comprehensive meeting. We observed that patients who refused surgery had statistically smaller aneurysms than those who accepted surgery (9% versus 26%). These smaller aneurysms were above the indication size, according to the literature. Conclusion One-quarter of patients who were indicated for elective surgical repair of aortic aneurysms rejected surgery after shared decision-making, which involved presenting patients with an informed consent form followed by a clarification meeting for them and their families to analyze each item. The only factor that significantly influenced a rejection of the procedure was the size of the aneurysm; patients who rejected surgery had smaller aneurysms than those who accepted surgery.

Is routine screening for silent pulmonary embolism justified in patients with deep vein thrombosis? / Existe justificativa para o rastreio de embolia pulmonar silenciosa em pacientes com trombose venosa profunda?

Abstract The incidence of asymptomatic pulmonary embolism (PE) exceeds 70% in patients with deep venous thrombosis (DVT), even in cases of distal deep vein thrombosis. We report the case of a patient with a diagnosis of DVT in the lower left limb associated with asymptomatic PE who presented late symptoms due to this same PE. The absence of acute symptoms and the late onset of symptoms could have provoked doubts about the most appropriate treatment, resulting in unnecessary interventions, if pulmonary embolism had not already been diagnosed with tomography. In the present case, we demonstrate that computed tomography angiography conducted at the time of DVT diagnosis accurately diagnosed PE and prevented any misinterpretation of recurrent DVT in a patient already being medicated, which could have been mistakenly interpreted as demonstrating failure of anticoagulant therapy. Such a situation could lead to unnecessary intervention to fit an inferior vena cava filter. We cannot suggest that a classic medical conduct should be reformulated simply on the basis of a case report. However, we would be remiss not to suggest that well-designed studies should be carried out in the future to assess the need for this examination in the acute phase.

Resumo A ocorrência de embolia pulmonar assintomática em pacientes com trombose venosa profunda tem uma incidência que excede 70%, mesmo nos casos de trombose venosa profunda distal. Relatamos o caso de um paciente com diagnóstico de trombose venosa profunda no membro inferior esquerdo associado a embolia pulmonar assintomática, que apresentou sintomas tardios devido a essa mesma embolia. A ausência de sintomas agudos e o surgimento de sintomas tardios pode suscitar dúvidas quanto ao tratamento mais adequado e resultar em intervenções desnecessárias, se o diagnóstico tomográfico de embolia pulmonar não tiver sido feito anteriormente. No presente caso, demonstramos que uma angiotomografia realizada no momento do diagnóstico de trombose venosa profunda detectou a embolia pulmonar e evitou uma interpretação incorreta de um evento trombótico recorrente na vigência de anticoagulação, o que por engano demonstraria uma falha na terapia anticoagulante. Essa situação pode levar a intervenções desnecessárias, como o implante de filtro de veia cava inferior. Entendemos que apenas um relato de caso não deve mudar uma conduta médica já estabelecida; no entanto, fomenta a discussão e estimula estudos que avaliem a necessidade de um exame diagnóstico pulmonar no momento do diagnóstico de trombose venosa profunda.

Signs of impending rupture in abdominal aortic and iliac artery aneurysms by computed tomography: Outcomes in 41 patients

OBJECTIVES: This study aimed to determine the prevalence of signs of impending rupture (SIR) in asymptomatic patients with abdominal aortic and iliac artery aneurysms, and to evaluate whether these signs were associated with rupture in asymptomatic patients. METHODS: This was a retrospective study of patients with abdominal aortic and iliac artery aneurysms identified on computed tomography (CT) over a 10-year period in a single center. The CT scans were reviewed by two reviewers, and patients with SIR were assigned to one of three groups: (1) early symptomatic (ES), (2) late symptomatic (LS), and (3) always asymptomatic (AA). The four main SIR described in the literature were investigated: 1) crescent sign, 2) focal wall discontinuity of circumferential calcifications, 3) aortic bulges or blebs, and 4) aortic draping. RESULTS: From a total of 759 aortic and iliac aneurysm reports on 2226 CT scans, we identified 41 patients with at least one SIR, and a prevalence of 4.14% in asymptomatic patients. Focal wall discontinuity of circumferential calcifications was the most common sign, and it was present in 46.3% of these patients (19/41); among these, 26 were repaired (ES: 9, LS: 2, AA: 15). Eleven asymptomatic patients underwent follow-up CT. The aneurysm increased in size in 6 of the 11 (54.5%) patients, and three ruptured (all with discontinuity of calcifications), one of which had no increase in diameter. CONCLUSIONS: The presence of focal wall discontinuity of circumferential calcifications was the most common SIR. There was a prevalence of all signs in less than 5% of asymptomatic patients. In unrepaired patients, the signs could be observed on follow-up CT scans with an increase in aneurysm size, indicating that the presence of SIR alone in the absence of other clinical factors or aneurysm characteristics is an insufficient indication for surgery.

Use of carbon dioxide for therapeutic decision-making in endoleaks: a case report / Uso de CO2 na tomada de decisão terapêutica de endoleak: relato de caso

Abstract Endovascular aneurysm repair is currently the most frequently treatment modality for infrarenal aortic aneurysms. Endoleaks are the most common cause of reintervention after endovascular aneurysm repair. It is often unclear which type of endoleak is the correct diagnose, making the treatment decision difficult. We report the case of a 72-year-old man with an endoleak two years after endovascular aneurysm repair. Images suggested a type III endoleak, but this was not confirmed by contrast aortography. We proceeded with the investigation using aortography with carbon dioxide and observed a type IA endoleak. This was successfully treated by implantation of a proximal cuff. A review of the literature shows that the role of carbon dioxide in endoleak management is still unclear. We present a case in which carbon dioxide was essential to both diagnosis and therapeutic decision-making in a type IA endoleak.

Resumo O tratamento endovascular dos aneurismas de aorta abdominal é atualmente a modalidade de tratamento mais comum. Os endoleaks representam a causa mais frequente de reintervenção após o tratamento endovascular. O diagnóstico do tipo de endoleak frequentemente é incerto, tornando o tratamento desafiador. Apresentamos o caso de um paciente de 72 anos, com endoleak após 2 anos de tratamento endovascular de aneurisma de aorta abdominal. Os exames de imagem pré-operatórios sugeriam um endoleak tipo III; entretanto, durante aortografia com contraste iodado, não foi possível identificá-lo. Optamos por realizar aortografia com dióxido de carbono (CO2), sendo, então, identificado um endoleak tipo IA, que foi tratado com sucesso com o uso de uma extensão (cuff) proximal. O papel do CO2 no diagnóstico de endoleaks ainda não está claro. Relatamos um caso em que o uso do CO2 foi essencial para o diagnóstico e para a decisão de tratamento do endoleak tipo IA.

Combination of topical agents and oxybutynin as a therapeutic modality for patients with both osmidrosis and hyperhidrosis / Uso combinado de agentes tópicos e oxibutinina para tratamento de pacientes com osmidrose e hiper-hidrose

Summary Introduction: The association of osmidrosis and hyperhidrosis often causes emotional and social problems that may impair the patients' quality of life. The purpose of our study was to analyze the therapeutic results of oxybutynin and topical agents in 89 patients with both osmidrosis and hyperhidrosis. Method: We conducted an observational study at two specialized centers of hyperhidrosis between April 2007 and August 2013. Eighty-nine (89) patients with both osmidrosis and hyperhidrosis were treated with oxybutynin and topical agents. Patients were evaluated before treatment and at 3 and 6 weeks after treatment started, by using the Quality of Life Questionnaire and the Sweating Evolution Scale. Results: Before treatment, 98% of the patients presented with poor or very poor quality of life. After six weeks of treatment, 70% stated their quality of life as being slightly better or much better (p<0.001) and nearly 70% of the patients experienced a moderate or great improvement in sweating and malodor. Improvement in osmidrosis was significantly greater when the axillary region was the first most disturbing site of hyperhidrosis. Conclusion: There was a significant improvement in quality of life and a reduction in sweating and malodor after six weeks of treatment with topical agents and oxybutynin in patients with both hyperhidrosis and osmidrosis. Therefore, clinical treatment should be considered before invasive techniques.

Resumo Introdução: A associação entre osmidrose e hiper-hidrose com frequência causa problemas emocionais e sociais que podem deteriorar a qualidade de vida dos pacientes. O objetivo deste estudo foi analisar os resultados terapêuticos do uso de oxibutinina associada a agentes tópicos em 89 pacientes com osmidrose e hiper-hidrose. Método: Nós conduzimos um estudo observacional em dois centros especializados em hiper-hidrose entre abril de 2007 e agosto de 2013. Oitenta e nove (89) pacientes com osmidrose associada a hiper-hidrose foram tratados com oxibutinina e agentes tópicos. Os pacientes foram avaliados antes do tratamento e após 3 e 6 semanas do início do tratamento, por meio do Questionário de Qualidade de Vida e da Escala de Evolução da Sudorese. Resultados: Antes do tratamento, 98% dos pacientes apresentavam qualidade de vida ruim ou muito ruim. Após seis semanas de tratamento, 70% classificou sua qualidade de vida como sendo pouco ou muito melhor (p<0.001) e aproximadamente 70% dos pacientes relataram melhora moderada ou grande de sudorese e odor. Houve melhora significativamente maior da osmidrose quando a região axilar era o sítio em que a hiper-hidrose mais incomodava. Conclusão: Houve melhora significativa da qualidade de vida e uma redução da sudorese e do odor após seis semanas de tratamento com agentes tópicos e oxibutinina em pacientes com hiper-hidrose associada a osmidrose. Dessa maneira, a terapia clínica deve ser considerada antes de técnicas invasivas.

Randomized trial of radiofrequency ablation versus conventional surgery for superficial venous insufficiency: if you don't tell, they won't know

OBJECTIVES: This study compared radiofrequency ablation versus conventional surgery in patients who had not undergone previous treatment for bilateral great saphenous vein insufficiency, with each patient serving as his own control. METHOD: This was a randomized controlled trial that included 18 patients and was carried out between November 2013 and May 2015. Each of the lower limbs of each patient was randomly assigned to undergo either radiofrequency ablation or conventional surgery. Clinical features (hyperpigmentation, hematoma, aesthetics, pain, skin burn, nerve injury, and thrombophlebitis) were evaluated at one week, one month, and six months postoperatively. Hemodynamic assessments (presence of resection or occlusion of the great saphenous vein and recurrent reflux in the sapheno-femoral junction and in the great saphenous vein) were performed at one month, six months, and 12 months postoperatively. The independent observer (a physician not involved in the original operation), patient, and duplex ultrasonographer were not made aware of the treatment done in each case. Clinicaltrials.gov: NCT02588911. RESULTS: Among the clinical variables analyzed, only the aesthetic evaluation by the physicians was significant, with radiofrequency ablation being considered better than conventional surgery (average, 0.91 points higher: standard deviation: 0.31; 95% confidence interval: -1.51, -0.30; p=0.003). However, in our study, we observed primary success rates of 80% for radiofrequency ablation and 100% for conventional surgery. CONCLUSIONS: If the physician is not required to inform the patient as to the technique being performed, the patient will not be able to identify the technique based on the signs and symptoms. Our study revealed that both techniques led to high levels of patient satisfaction, but our results favor the choice of conventional surgery over radiofrequency ablation, as patients who underwent conventional surgery had better hemodynamic assessments.

Endovascular revascularization of TASC C and D femoropopliteal occlusive disease using carbon dioxide as contrast / Revascularização endovascular de doença oclusiva fêmoro-poplítea TASC C e D com o uso de dióxido de carbono como meio de contraste

ABSTRACT Objective To analyze the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO2 as primary contrast in patients with no formal contraindication to iodine, aiming to decrease allergic reactions and potential nephrotoxicity in high-risk patients. Methods We describe the results of ten angioplasties of TASC C and D femoropopliteal lesions using CO2 as primary contrast in patients with high risk for open revascularization and no formal contraindication to iodine. We analyzed feasibility of the procedures, complications, quality of the angiographic images, clinical and surgical outcomes, and costs of C and D lesions treated using CO2 as contrast medium. Results The use of CO2 in C and D lesions needed iodine complementation in most of the cases (nine cases) but decreased the potential nephrotoxicity of iodine contrast medium by the reduction of its volume in this group of high-risk patients. The extension of the arterial lesions was the factor that most contributed to the need for iodine supplementation due to the difficulty to visualize the refill after a long arterial occlusion. Conclusion The use of CO2 as contrast in patients with C and D lesions with no restriction for iodine contrast medium was an alternative that did not dismiss the need of iodine supplementation in most of the cases, but could decrease the potential nephrotoxicity of iodine constrast medium.

RESUMO Objetivo Analisar os resultados de dez angioplastias de lesões fêmoro-poplíteas TASC C e D utilizando CO2 como meio de contraste primário em pacientes sem restrição ao meio de contraste iodado com o objetivo de diminuir reações alérgicas e potencial de nefrotoxicidade em pacientes de alto risco. Métodos Descrevemos os resultados de dez angioplastias de lesões fêmoro-poplíteas TASC C e D utilizando CO2 como meio de contraste primário em pacientes de alto risco para revascularização aberta e sem contraindicação formal a iodo. Analisamos possibilidade de execução dos procedimentos, complicações, qualidade das imagens obtidas, desfechos clínicos e cirúrgicos e custos das lesões C e D tratadas com CO2 como meio de contraste. Resultados O uso de CO2 nas lesões C e D necessitou de complementação de iodo na maioria dos casos (nove casos), porém reduziu o potencial de nefrotoxicidade do meio de contraste iodado, diminuindo seu volume nesse grupo de pacientes de alto risco. A extensão das lesões arteriais foi o fator que mais contribuiu para necessidade de suplementação de iodo, devido à dificuldade de visualizar o reenchimento após oclusão arterial longa. Conclusão O uso de CO2 como contraste em pacientes com lesões C e D sem restrição ao meio de contraste iodado foi uma alternativa que não excluiu a necessidade de suplementação com iodo na maioria dos casos, porém pôde diminuir o potencial de nefrotoxicidade do meio de contraste iodado.

Carbon dioxide contrast medium for endovascular treatment of ilio-femoral occlusive disease

OBJECTIVES:Compare the use of carbon dioxide contrast medium with iodine contrast medium for the endovascular treatment of ilio-femoral occlusive disease in patients without contraindications to iodine.MATERIALS AND METHODS:From August 2012 to August 2014, 21 consecutive patients with ilio-femoral occlusive disease who were eligible for endovascular treatment and lacked contraindications to either iodine contrast or carbon dioxide were randomized into the carbon dioxide or iodine groups and subjected to ilio-femoral angioplasty.We analyzed the feasibility of the procedures, the surgical and clinical outcomes, the procedure lengths, the endovascular material costs, the contrast costs and the quality of the angiographic images in each group.RESULTS:No conversions to open surgery and no contrast media related complications were noted in either group. A post-operative femoral pulse was present in 88.9% of the iodine group and 80% of the carbon dioxide group. No differences in procedure length, endovascular material cost or renal function variation were noted between the groups. Four patients in the carbon dioxide group required iodine supplementation to complete the procedure. Contrast media expenses were reduced in the carbon dioxide group. Regarding angiographic image quality, 82% of the carbon dioxide images were graded as either good or fair by observers.CONCLUSIONS:The use of carbon dioxide contrast medium is a good option for ilio-femoral angioplasty in patients without contraindications to iodine and is not characterized by differences in endovascular material costs, procedure duration and surgical outcomes. In addition, carbon dioxide has lower contrast expenses compared with iodine.

Carbon dioxide as a substitute for iodine contrast in arteriography during embolectomy / Uso de dióxido de carbono como substituto ao contraste iodado em arteriografia durante embolectomia

Acute limb ischemia can be potentially harmful to the limb and life threatening. Renal failure is a possible outcome associated with release of products of ischemic limb reperfusion. Some authors reported the benefit of performing angiography after embolectomy, even though iodine contrast is also nephrotoxic. We report a case of embolectomy on a patient with renal insufficiency in whom carbon dioxide was used as a substitute for iodine contrast.

A isquemia aguda de membro pode ser danosa para o membro e para a vida. A insuficiência renal é um desfecho possível associado à liberação dos produtos da reperfusão do membro isquêmico. Alguns autores relatam o benefício de realização de angiografia após embolectomia, apesar do contraste iodado também ser nefrotóxico. Relatamos um caso de embolectomia em uma paciente com insuficiência renal, em que o dióxido de carbono foi utilizado como substituto para o contraste iodado.

Uso combinado de endoprótese GORE TAG® e Gore Exculder® para tratamento de aneurisma de aorta abdominal com angulação extrema / Combined use of GORE TAG® and Gore Exculder® endografts for treatment of abdominal aortic aneurysm with severe angulation

O avanço tecnológico da cirurgia endovascular no tratamento de aneurismas de aorta vem permitindo que uma maior quantidade de pacientes, antes considerados inaptos para essa abordagem, beneficie-se dessa modalidade terapêutica. Apesar da atual disponibilidade de endopróteses com alta conformabilidade, casos com anatomia desfavorável permanecem um desafio para os cirurgiões. Descrevemos um caso anatomicamente desfavorável, resolvido com sucesso pela técnica endovascular, utilizando-se uma manobra não convencional.

The advances in endovascular surgery for treatment of aortic aneurysms have allowed a greater number of patients, who were previously considered unsuitable for the approach, to benefit from this therapeutic modality. Despite the current availability of highly comfortable endografts, cases with unfavorable anatomy remain a challenge for surgeons. We report a case with difficult anatomy that was successfully managed using an unconventional endovascular technique.

Public private partnership in vascular surgery / Parceria público-privada em cirurgia vascular

Objective To describe and analyze the results of a public-private partnership between the Ministry of Health and a private hospital in a project of assistance and scientific research in the field of endovascular surgery. Methods: The flows, costs and clinical outcomes of patients treated in a the public-private partnership between April 2012 and July 2013 were analyzed. All patients underwent surgery and stayed at least one day at the intensive care unit of the private hospital. They also participated in a research protocol to compare two intravenous contrast media used in endovascular surgery (iodinated contrast and carbon dioxide). Results A total of 62 endovascular procedures were performed in 57 patients from the public healthcare system. Hospital and endovascular supplies expenses were significantly higher as compared to the amount paid by the Unified Health System (SUS - Sistema Único de Saúde) in two out of three disease groups studied. Among outpatients, the average interval between appointment and surgery was 15 days and, in hospitalized patients 7 days. All procedures were successful with no conversion to open surgery. The new contrast medium studied - carbon dioxide – was effective and cheaper. Conclusion The waiting time for patients between indication and accomplishment of surgery was significantly reduced. Public-private partnerships can speed up care of patients from public health services, and generate and improve scientific knowledge. .

Objetivo Descrever e analisar os resultados de parceria público-privada entre o Ministério da Saúde e um hospital privado em projeto de assistência e pesquisa científica na área de cirurgia endovascular. Métodos: Foram analisados fluxos, custos e resultados clínicos dos pacientes atendidos numa parceria público-privada entre abril de 2012 e julho de 2013. Todos os pacientes foram operados, ficaram pelo menos um dia na unidade de terapia intensiva do hospital privado e participaram de um protocolo de pesquisa para comparação entre dois contrastes endovenosos para cirurgia endovascular (contraste iodado e dióxido de carbono). Resultados Foram realizados 62 procedimentos endovasculares em 57 pacientes provenientes do sistema público. Os gastos hospitalares e com material endovascular mostraram-se significativamente maiores em relação ao que é pago pelo Sistema Único de Saúde (SUS) em dois dos três grupos de doenças estudados. Entre os pacientes ambulatoriais, o intervalo médio entre a consulta e a cirurgia foi de 15 dias e, nos internados, 7 dias. Todos os procedimentos foram bem sucedidos, sem conversão para cirurgia aberta. O novo contraste estudado, o dióxido de carbono, mostrou-se eficaz e mais barato. Conclusão O tempo de espera dos pacientes entre indicação cirúrgica e sua realização foi significativamente reduzido. Parcerias público-privadas podem trazer agilidade no atendimento dos pacientes do SUS, permitindo também geração de conhecimento científico. .