Abnormal obturator artery with ipsilateral inferior epigastric artery passed behind the femoral vein / Arteria obturatriz anómala con arteria epigástrica inferior ipsilateral que cruza posterior a la vena femoral

SUMMARY: Clear awareness of the vascular variations is critical in surgeries, which may cause massive hemorrhage during surgical procedures. During educational dissection of a male cadaver, we encountered a combined variation of the left obturator artery and ipsilateral aberrant inferior epigastric artery. The left obturator artery originated from the external iliac artery, then coursed inward, adherent to the superior pubic ramus. The left inferior epigastric artery originated from the femoral artery, and coursed behind the femoral vein. These anatomical variations shown in one person were extremely rare. This is particularly true with regard to these variations while performing pelvic and inguinal region surgeries.

El conocimiento claro de las variaciones vasculares es fundamental en las cirugías, ya que pueden causar una hemorragia masiva durante los procedimientos quirúrgicos. Durante la disección educativa de un cadáver de sexo masculino, encontramos una variación combinada de la arteria obturatriz izquierda y la arteria epigástrica inferior ipsilateral aberrante. La arteria obturatriz izquierda se originaba en la arteria ilíaca externa, luego discurrió hacia medial, adhiriéndose a la rama púbica superior. La arteria epigástrica inferior izquierda se originaba en la arteria femoral y discurría por detrás de la vena femoral. Estas variaciones anatómicas mostradas en una sola persona son extremadamente raras. Esto es importante de conocer estas variaciones cuando se realizan cirugías de las regiones pélvica e inguinal.

Thrombectomy in a severe case of iliofemoral venous thrombosis involving the deep femoral vein via a single percutaneous access from the jugular vein: case report and description of the technique / Trombectomia em caso grave de trombose venosa iliofemoral afetando a veia femoral profunda pela técnica de punção e sessão única realizada pela veia jugular: relato de caso e descrição da técnica

ABSTRACT: Iliac vein thrombectomy is usually performed via access through veins located in the lower limbs, which makes it impossible to treat the deep femoral vein, which in turn is an important inflow route to the iliac vein stent. We describe a clinical case and the previously unpublished technique of percutaneous thrombectomy, angioplasty, and stent implantation performed in a single session and with a single access, obtained via the internal jugular vein.

RESUMO: A trombectomia mecânica venosa ilíaca geralmente é realizada por acesso em veias localizadas nos membros inferiores, o que impossibilita o tratamento da veia femoral profunda, que, por sua vez, é uma importante via de influxo ao stent venoso ilíaco. Descrevemos um caso clínico em que foi aplicada a técnica inédita de trombectomia percutânea, angioplastia e implante de stent, realizada por sessão e acesso único, obtido na veia jugular interna.

Avaliação ultrassonográfica de variações anatômicas entre vasos femorais realizada por estudantes de medicina / Ultrasonographic evaluation of anatomical variations in femoral vessels done by medical students

Introdução: A punção venosa central é um procedimento médico tradicionalmente realizado seguindo os marcadores anatômicos como referência para atingir o vaso, às cegas. No entanto, nem sempre o sucesso nessa técnica é alcançado, fato que se deve principalmente às variações anatômicas. A ultrassonografia point of care (US-POC) é utilizada para auxiliar a cateterização central por visualização direta do vaso, aumentando a segurança do procedimento. Objetivo: Avaliar a prevalência das variações anatômicas de vasos femorais através da utilização da US-POC por estudantes de medicina submetidos a curto período de treinamento. Material e Métodos: Cinco estudantes de medicina, sem experiência prévia em US-POC, foram submetidos a oito horas de treinamento teórico-prático. Foram avaliados os vasos femorais de cem voluntários. Resultados: A veia femoral direita foi encontrada mais frequentemente na posição medial (43%) em relação à artéria femoral direita. À esquerda, a posição posteromedial foi a mais observada (45%).Conclusão: A técnica tradicional de punção de acesso central se baseia em marcadores anatômicos e não leva em consideração as variações anatômicas existentes. Um treinamento de curto período para uso da US-POC é capaz de capacitar o profissional para reconhecer o posicionamento real dos vasos e evitar punções inadvertidas.

Introduction: Central vein puncture is a medical procedure traditionally done following anatomical landmarks as a reference to successfully achieving the vessel. However, this traditional technique is commonly unsuccessful due to anatomical variations that may be found. Point of care ultrasonography (POC-US) is used to assist central catheterization by directly visualizing the vessel, increasing procedure security and minimizing risks. Objective: Evaluate anatomical variations prevalence in femoral vessels, utilizing POC-US, done by medical students submitted to a short period of time training in ultrasonography. Material and Methods: Five medical students, without previous experience on the use of ultrasonography, were submitted to an eight-hour theorical practical training in POC-US. The students evaluated one hundred femoral vessels of volunteers. Results: The right limb femoral vein was found more frequently in the medial position (43%) in comparison to the right limb femoral artery. On the left limb, the posteromedial position was the most found (45%). Conclusion: The insertion of a central catheter following the traditional technique is based on anatomical landmarks, and does not take into account existing anatomical variations. With a short period of training, POC-US is capable of qualifying professionals to acknowledge the real location of the vessel and avoid inadvertent punctures and complications.

An unusual case of femoral arteriovenous fistula associated with acute limb ischemia following femoral vein catheterization for hemodialysis / Um caso incomum de fístula arteriovenosa femoral associada a isquemia aguda de membro após cateterização da veia femoral para hemodiálise

Abstract Co-occurrence of acute limb ischemia (ALI) and arteriovenous fistula (AVF) as a manifestation of inadvertent arterial injury during percutaneous femoral vein dialysis catheter insertion is a rare and dangerous, but preventable complication. Iatrogenic femoral AVF commonly presents late, with leg swelling or high output cardiac failure. However, the co-occurrence of a femoral AVF with both progressive leg swelling, and acute thromboembolism has not been previously reported. We report the case of an iatrogenic femoral AVF with superficial femoral artery (SFA) thrombosis and distal embolism in a 53-year-old female who underwent percutaneous femoral access for temporary hemodialysis. Both the SFA and AVF were managed with open surgical repair.

Resumo A coocorrência de isquemia aguda de membro (IAM) e fístula arteriovenosa (FAV) como uma manifestação de lesão arterial inadvertida durante a inserção de cateter para hemodiálise por via femoral percutânea é uma complicação rara e perigosa, porém evitável. A FAV femoral iatrogênica geralmente tem apresentação tardia, com edema dos membros inferiores ou insuficiência cardíaca de alto débito. No entanto, a coocorrência de FAV femoral com edema progressivo dos membros inferiores e tromboembolismo agudo não foi previamente relatada. Relatamos o caso de uma FAV femoral iatrogênica com trombose da artéria femoral superficial (AFS) e embolia distal em uma paciente do sexo feminino, 53 anos, submetida à acesso femoral percutâneo para hemodiálise temporária. Tanto a AFS quanto a FAV foram manejadas com reparo cirúrgico aberto.

A brief comment on vasa vasorum of human saphenous vein: relevance for coronary artery bypass surgery

Abstract The importance of the vasa vasorum and blood supply to the wall of human saphenous vein (hSV) used for coronary artery bypass grafting (CABG) is briefly discussed. This is in the context of the possible physical link of the vasa vasorum connecting with the lumen of hSV and the anti-ischaemic impact of this microvessel network in the hSV used for CABG.

Impacto de la cateterización venosa central percutánea bajo guía ecográfica en una terapia intensiva pediátrica polivalente / Impact of ultrasound-guided percutaneous central venous catheterization at a general pediatric intensive care unit

Introducción: La cateterización venosa central es un procedimiento usual en Unidades de Cuidados Intensivos (UCI). El ultrasonido (US) para guiar la cateterización, ofrece ventajas, permitiendo tener una imagen topográfica precisa del vaso, reduciendo las complicaciones, el tiempo y el número de punciones. Objetivo: determinar, si la US en la colocación de catéteres venosos centrales (CVC), podría disminuir el número de punciones y lograr la cateterización exitosa. Población y métodos: Estudio descriptivo, prospectivo de los CVC colocados mediante punción guiada por US, en una UCI polivalente del Hospital de Pediatría Juan P. Garrahan, entre el año 2018 al 2019. Población: pacientes de 1 mes a 18 años que requirieron colocación de un CVS por US. Se consideró significativo un valor de p< 0.05. Resultados: VYI en 66 pacientes (43,5%), VF fue en 86 pacientes (56,5%). 86 (56,5%) CVC, fueron insertados en el primer intento y 66 (43,5%), requirieron más de un intento. Las inserciones en VYI fueron exitosas en el primer intento en 46 pac. (53,5%) 20 pac. requirieron más de un intento (30,3%) p 0,004 OR 0,37 (IC 95% 0,18-0,78. En <6 meses los CVC colocados en VYI tuvieron menos riesgo de requerir más de un intento, con respecto a aquellos en los cuales se eligió la VF, p 0,0026 OR 0,31 (IC 95% 0,12 -0,75). 5,2% presentaron complicaciones, no hubo mortalidad relacionada al procedimiento. Conclusiones: La inserción de CVC guiados por US fue segura y significativamente exitosa en el primer intento cuando el vaso de elección fue la VYI, especialmente en < 6 meses (AU)

IIntroduction: Central venous catheterization is a common procedure in intensive care units (ICU). The use of ultrasound (US) to guide catheterization offers advantages, allowing for an accurate topographic image of the vessel, reducing complications as well as time and number of punctures. Objective: To determine whether the use of US for the placement of central venous catheters (CVCs) may decrease the number of punctures and achieve successful catheterization. Patients and methods: A descriptive, prospective study was conducted of CVCs placed by US-guided puncture at a general ICU of Hospital de Pediatría Juan P. Garrahan between 2018 and 2019. Patients from 1 month to 18 years of age who required US-guided placement of a CVC were included. A p< 0.05 was considered significant. Results: The internal jugular vein (IJV) was used in 66 (43.5%) and the femoral vein (FV) in 86 patients (56.5%). Overall, in 86 (56.5%) CVC were inserted on the first attempt and 66 (43.5%) required more than one attempt. Insertions into the VYI were successful on the first attempt in 46 (53.5%) patients and 20 (30.3%) patients required more than one attempt, p 0.004; OR 0.37 (95% CI 0.18-0.78). In patients <6 months CVCs placed in the IJV had a lower risk of requiring more than one attempt compared to those in which the FV was chosen, p 0.0026 OR 0.31 (95% CI 0.12 -0.75). Complications occurred in 5.2%; no procedure-related mortality was observed. Conclusions: US-guided insertion of CVC was safe and significantly successful on the first attempt when the vessel of choice was the IJV, especially in patients < 6 months (AU)

Saphenous vein vasa vasorum as a potential target for perivascular fat-derived factors

Abstract Perivascular adipose tissue (PVAT) is a source of factors affecting vasomotor tone with the potential to play a role in the performance of saphenous vein (SV) bypass grafts. As these factors have been described as having constrictor or relaxant effects, they may be considered either beneficial or detrimental. The close proximity of PVAT to the adventitia provides an environment whereby adipose tissue-derived factors may affect the vasa vasorum, a microvascular network providing the vessel wall with oxygen and nutrients. Since medial ischaemia promotes aspects of graft occlusion the involvement of the PVAT/vasa vasorum axis in vein graft patency should be considered.

Incidencia, tasa de éxito, complicaciones y factores predictores de empleo de la vía femoral en procedimientos percutáneos de extracción de electrodos / Incidence, success rate, complications and predictive factors of the use of the femoral route for the removal of the electrodes after percutaneous procedures

Resumen Introducción: en los procedimientos de extracción de electrodos, la vía femoral se usa cuando la vía superior ha fracasado. Objetivo: describir la incidencia, el éxito, las complicaciones y los predictores de uso de la vía femoral. Métodos: se realizó un análisis de la incidencia del uso de la vía femoral y los factores predictores en pacientes a quienes se les realizó extracción de electrodos entre noviembre de 2011 y noviembre de 2017. Resultados: se incluyeron 85 pacientes, con edad media de 62,36 ± 11,15 años. El 38,9% de los dispositivos eran marcapasos. Se extrajeron 135 electrodos, 59,3% de fijación pasiva. La mediana de tiempo desde el implante fue de 102 (60-174) meses. Se empleó la ruta femoral en el 25,9% de los procedimientos. Se obtuvo éxito clínico en el 92,9% de los pacientes. La extracción no fue exitosa en el 22,7% de los procedimientos cuando se usó la vía femoral, en comparación con el 1,6% cuando se usó la vía superior (p 0,004). La extracción no fue completa en el 36,4% de los procedimientos cuando se empleó la vía femoral en comparación con el 9,5% por vía superior (p 0,007). Los factores que predijeron el empleo de la ruta femoral fueron la presencia de electrodos de fijación pasiva [OR IC 95% 13,69 (3,06-62,5) p 0,001] y el tiempo desde el implante del electrodo [OR IC 95% por cada 10 meses 1,04 (1,00-1,09) p 0,044]. Conclusiones: se empleó la ruta femoral en el 25,9% de los procedimientos. No fue eficaz en el 22,7% de las intervenciones. Los factores que predijeron su utilización fueron la presencia de electrodos de fijación pasiva y el tiempo desde el implante del electrodo.

Abstract Introduction: The femoral route is used in electrode removal procedures when the upper route has failed. Objective: To describe the incidence, success rate, complications and predictive factors for the use of the femoral route. Methods: An analysis was performed on the incidence of use of the femoral route and the predictive factors in patients in whom electrode removal was carried out between November 2011 and November 2017. Results: The study included 85 patients with a mean age of 62.36 ± 11.5 years. Pacemakers made up 38.9% of the devices. A total of 135 electrodes, 59.3% of passive fixation, were removed. The median time since the implant was 102 (60-174) months. The femoral route was used in 25.9% of the procedures. Clinical success was achieved in 92.9% of the patients. The removal was not successful in 22.7% of the procedures when the femoral route was used, compared to 1.6% when the upper route was used (P = .004). The removal was not completed in 36.4% of the procedures when the femoral route was used, compared to 9.5% with the upper route (P = .007). The factors that predicted the use of the femoral route were the presence of passive-fixation electrodes (OR = 13.69: 95% CI; 3.06 - 62.5, P = .001), and the time since the electrodes were implanted (OR = 1.04, 95% CI; 1.00 - 1.09, P = .044, for every 10 months). Conclusions: The femoral route was employed in 25.9% of the procedures. It was not effective in 22.7% of the interventions. The factors that predicted its use were the presence of passive-fixation electrodes and the time since the electrode implant.

Caso Clínico: Rotura y Embolización de Catéter Femoral / Case Report: Rupture and Embolization of a Femoral Catheter

INTRODUCCIÓN:La embolización de cuerpos extraños intravasculares es una complicación poco frecuente; sin embargo, está asociada a alteraciones cardíacas y pulmonares en más del 50% de los casos. Actualmente se prefiere realizar el manejo utilizando técnicas de extracción por cateterismo cardíaco, esto debido a la naturaleza menos invasiva del procedimiento y a las menores tasas de mortalidad y complicaciones asociadas. A continuación se presenta un reporte de caso donde se realizó la extracción un catéter intracardiaco mediante vía percutánea. CASO CLÍNICO: Lactante de sexo masculino, de 51 días de vida, con antecedentes de prematuridad extrema y peso adecuado para edad gestacional, ingresado en el servicio de neonatología; a quien como acceso vascular central se le colocó un catéter percutáneo femoral. Tras el retiro del mismo se apreció rotura y embolización de los dos tercios distales; la evaluación radiológica evidenció catéter a nivel de cavidades cardíacas derechas. EVOLUCIÓN: Se inició antibioticoterapia por el riesgo de infección asociado. De forma exitosa se realizó la extracción del cuerpo extraño por intervencionismo percutáneo; el paciente evolucionó favorablemente, no presentó ninguna complicación. CONCLUSIÓN: La rotura y embolización del catéter es un evento poco frecuente que incrementa la morbimortalidad de los pacientes ingresados en neonatología. La extracción percutánea debe ser la primera opción por la eficacia y seguridad del procedimiento.(au)

BACKGROUND: The embolization of foreign intravascular bodies is a rare complication; however, it is associated with cardiac and pulmonary dysfunction in more than 50% of cases. Currently, it is preferred to perform the management using extraction techniques by cardiac catheterization; this is explained by the less invasive nature of the procedure and the lower mortality and complications rates. The following is a case report where an intracardiac catheter was extracted by a percutaneous procedure. CASE REPORT: Male, 52-day-old infant, with history of extreme prematurity and adequate weight for gestational age; hospitalized in the neonatology service; as central vascular access a percutaneous femoral catheter was placed. After removal, rupture and embolization of the distal two thirds were observed; the radiological evaluation showed a catheter at the level of right heart cavities. EVOLUTION: By the associated infection risk, antibiotic therapy was initiated. The foreign body was extracted successfully by percutaneous intervention; the patient presented a favorable evolution without any complications. CONCLUSIONS: The catheter rupture and embolization is a rare event that increases morbidity and mortality rates of patients admitted to neonatology. Percutaneous extraction should be the first option by the procedure efficacy and safety.(au)

Effect of the lateral tilt position on femoral vein cross-sectional area in anesthetized adults

BACKGROUND: A lateral tilt position can affect the size of the femoral vein (FV) due to increased venous blood volume in the dependent side of the body. METHODS: Forty-two patients, aged 20–60 years, were enrolled in this study. The crosssectional area (CSA), anteroposterior, and transverse diameters of the FV were measured 1 cm below the left inguinal line using ultrasound. The value of each parameter was recorded in the following four positions: (1) supine, (2) supine + 10° left-lateral tilt (LLT), (3) 10° reverse Trendelenburg (RT), and (4) RT + LLT. RESULTS: CSAs of the left FV in the supine, supine + LLT, RT, RT + LLT positions were 0.93 ± 0.22, 1.11 ± 0.29, 1.17 ± 0.29, and 1.31 ± 0.32 cm2, respectively. Compared to the supine position, there was a significant increase in CSA and anteroposterior diameter according to the three changed positions. The transverse diameter of the left FV was significantly increased in supine + LLT, RT, RT + LLT positions compared to that in the supine position (P = 0.010, P = 0.043, P = 0.001, respectively). There was no significant difference in the transverse diameter of the left FV between the supine + LLT and RT positions (P = 1.000). CONCLUSIONS: Adding LLT to the supine and RT positions increased the CSA of the unilateral FV significantly.

Feasibility and Effectiveness of Direct Puncture and Onyx Embolization for Transverse Sinus Dural Arteriovenous Fistula

Direct puncture and embolization of the transverse sinus (TS) for treatment of dural arteriovenous fistula (DAVF) is typically performed with coils with or without glue. We report a case of DAVF at the left TS that was treated with Onyx embolization via direct puncture of the TS. A 75-year-old woman presented with tremor, festinating gait, and dysarthria. A left TS-DAVF with retrograde superior sagittal sinus and cortical venous reflux (Cognard type IIa+b) was identified on cerebral angiography, and both TSs were occluded with thrombi. We considered that achieving complete cure by transvenous embolization via the femoral vein or transarterial embolization via occipital feeders would be difficult. Thus, we performed a small craniotomy at the occipital bone to puncture the TS. The midportion of the TS was directly punctured with a 21-G microneedle under fluoroscopic guidance. We inserted a 5-F sheath into the TS. A microcatheter was then navigated into the affected sinus. Coils were placed through the microcatheter to support Onyx formation by reducing the pressure of shunting flow. Onyx embolization was performed with the same microcatheter. The DAVF was almost completely occluded except for the presence of minimal shunting flow to the proximal TS. After 1 week, time-of-flight magnetic resonance angiography showed complete resolution of DAVF. The patient showed resolved tremor and markedly improved mental status at 1-month follow up. Direct puncture and embolization of the TS using coils and Onyx is effective and feasible method for the treatment of DAVF when other approaches seem difficult.

Comparison of Treatment Result Between Anticoagulation Alone and Catheter-Directed Thrombolysis Plus Anticoagulation in Acute Lower Extremity Deep Vein Thrombosis

PURPOSE: Deep vein thrombosis (DVT) is the third most common cause of cardiovascular morbidity and mortality. Anticoagulation has been the primary treatment modality for acute DVT. However, catheter-directed thrombolysis (CDT) has recently become widely accepted as an additional therapy to anticoagulation. We assessed comparative outcomes in patients with acute DVT who underwent anticoagulation therapy alone (ACA) group and those treated with CDT group. MATERIALS AND METHODS: We retrospectively reviewed medical records of 149 patients with DVT from January 2011 to December 2015. We compared patients who received ACA group (n=120) and those who received CDT plus anticoagulation (CDT group, n=29). We analyzed the prevalence of lesions, thrombus removal rate in each lesion, and recurrence-free rate between the two groups. RESULTS: We found thrombus involvement in a total of 281 lesions in the ACA group and 85 lesions in the CDT group. For the distribution of lesions in each group, those in the femoral vein accounted for 34.2% of all lesions and those in the popliteal vein accounted for 31.7%. During follow-up, the overall thrombus removal rate was 91.1% in the ACA group and 87.0% in the CDT group (P=0.273). The recurrence-free rate was higher in the CDT group in a log-rank test; however, there was no statistically significant difference between the two groups (P=0.594). CONCLUSION: According to our results, there was no significant difference in thrombus removal and recurrence-free rates between the CDT and ACA groups. ACA still has an important role in the treatment of DVT.

Cut-down method for perm catheter insertion in patients with completely occluded internal jugular vein

The primary site for a hemodialysis catheter insertion is the right internal jugular vein (IJV) followed by the left IJV and subclavian vein. In cases when veins of the upper extremities are exhausted, femoral veins are an alternative insertion location. Femoral catheter insertions should only be used for short periods because of the increased risk of infection. There is a percutaneous technique to recanalize occluded central veins for hemodialysis catheter insertion. We experienced success with a cut-down method for permcath through a completely occluded IJV. We, therefore, find surgical recanalization to be better than percutaneous method in terms of cost and safety.

Tuneled catheters in femoral vein: does the length makes any difference? / ¿Catéteres femorales tunelizados para hemodiálisis, su longitud hace diferencia?

Abstract Objective: To establish if 23 cm length, tunneled catheters, are associated to better outcomes than 19 cm ones. Patients, Materials and Methods: Patients with CKD G5D, which the only vascular access alternative was the femoral vein. In these patients, the performance of different lengths of catheters was compared. Results: During 103 months (from February 2009 to September 2017), 30 femoral tunneled catheters were implanted in 19 patients; 15 each group, mean age was 56.3 years. Thirteen (68.4%) were men. Catheters with similar design, but with different lengths, yield comparable results in patency, complications and cause of removal. Conclusions: We suggest using femoral catheters with lengths from 25 to 55 cm (from the cuff to the tip) to obtain best results because such lengths are necessary to reach positions near the right atrium.

Resumen Objetivo: establecer si la implantación de catéteres femorales tunelizados de 23 cm genera mejores resultados que los de 19 cm . Pacientes, materiales y métodos: pacientes con enfermedad renal crónica estadio 5, en los que se agotaran todos los accesos vasculares, siendo la vena femoral su última alternativa. En ellos se compararon los resultados en cuanto a eficiencia y complicaciones de implantar catéteres con diferente longitud. Resultados: durante 103 meses (de febrero del 2009 a septiembre del 2017), 30 catéteres femorales tunelizados fueron implantados en 19 pacientes; 15 en cada grupo, edad promedio de los pacientes 56,3 años, 13 (68,4%) hombres. Los dos catéteres con diseño semejante, pero diferente longitud dieron lugar a resultados parecidos en cuanto a tiempo de funcionamiento, complicaciones y motivo de retiro. Conclusiones: sugerimos que los catéteres femorales tunelizados para hemodiálisis deben de tener longitudes entre 28 a 55 cm (del retenedor a la punta) para lograr una mayor eficiencia, longitud suficiente que permita alcanzar territorios cercanos a la aurícula derecha.

Implante de marcapasso definitivo por via femoral: uma alternativa eficaz e segura / Permanent pacemaker implantation via the femoral vein: an effective and safe alternative

Homem, 26 anos, portador de lúpus eritematoso sistêmico, com nefrite em hemodiálise, apresentou endocardite infecciosa de valva aórtica, com abcesso em septo fibroso, com fluxo para a cavidade direita, sendo indicada troca valvar aórtica e fechamento do orifício septal com patch de pericárdio. Evoluiu após o procedimento com bloqueio atrioventricular total (BAVT), sendo implantado marcapasso (MP) definitivo por veia subclávia direita (VSCD). Após 6 meses, apresentou hematoma infectado em loja do MP, sendo indicado explante do mesmo. Como o paciente era dependente do dispositivo, foi posicionado MP provisório por veia femoral (VF) em ventrículo direito (VD), até a resolução do quadro infeccioso e a liberação para implante de novo sistema endocárdico. No entanto, em virtude da presença de fístula arteriovenosa (FAV) em membro superior esquerdo (MSE) e trombose de VSCD diagnosticada por venografia em sala, optouse por implante de MP epicárdico. Vinte e três dias após este implante, evoluiu com falha de captura por aumento de limiar de estimulação. Foi posicionado novo MP provisório por VF. Realizada tentativa de implante de MP por veia jugular interna direita, sem sucesso, por não progressão do guia (trombose). Optou-se por implante de MP definitivo por VF direita, com eletrodo de 85cm e implante de unidade geradora em bolsa confeccionada em fossa ilíaca direita. Limiar ventricular e impedância se mantiveram estáveis durante toda a internação. Recebeu alta, com avaliação após 6 meses sem intercorrências, com bom limiar e impedância. A via femoral é uma alternativa não usual, porém segura e eficaz para implante de MP definitivo em pacientes nos quais o acesso central alto e epicárdico não é possível

A 26-year-old male with systemic lupus erythematosus with hsis nephritis had an infectious endocarditis of the aortic valve with abscess in the fibrous septum with flow into the right cavity. Being indicated aortic valve replacement and closure of the septal orifice with pericardial patch. The patient evolved after the procedure with total atrioventricular block (BAVT), and a definitive pacemaker (PM) was implanted by right subclavian vein (RSV). After six months, he presented an infected hematoma in the device, being explanted. As the patient was device dependent, temporary femoral vein (FV) was placed in the right ventricle (RV), until the resolution of the infectious condition and the release to implant of a new endocardial system. However, due to the presence of arteriovenous fistula (AVF) in the left upper limb (LUL) and right subclavian vein thrombosis diagnosed by venography, we opted for epicardial PM implantation. Twenty-three days after this implant evolved with failed capture by increasing stimulation threshold. New provisional PM was placed by FV. An attempt was made to implant PM by right internal jugular vein, without success, for non-progression of the guide (thrombosis). We chose to implant the definitive PM by right FV, with an electrode of 85cm and implant of a generating unit in the right iliac fossa. Ventricular threshold and impedance remained stable throughout the hospitalization. He was discharged, with evaluation after 6 months without intercurrences, with good threshold and impedance. The femoral route is an unusual but safe and effective alternative for definitive MP implantation in patients where high central and epicardial access is not possible

Mid-term results of peripheral cannulation after robotic cardiac surgery

Abstract Introduction: Various surgical procedures for minimally invasive cardiac surgery have been described in recent decades as alternatives to median sternotomy. Cardiopulmonary bypass via femoral arterial and venous cannulation is the foundation of these procedures. In this study, we evaluated the mid-term outcomes of femoral cannulation performed with U-suture technique in patients undergoing robotic heart surgery. Methods: A total of 216 patients underwent robotic-assisted cardiac surgery between January 2013 and April 2017. Cardiopulmonary bypass was performed via femoral artery, jugular, and femoral vein cannulation, and a Chitwood clamp was used for aortic occlusion. A total of 192 patients attended the outpatient follow-up, and femoral arterial and venous flow pattern was examined using Doppler ultrasound (DUS) in 145 patients. Results: Hospital mortality occured in 4 of the 216 (1.85%) cases, but there was no late mortality in this patient group. Postoperatively, seroma (n=9, 4.69%) and cannulation site infection (n=3, 1.56%) were managed with outpatient treatment. DUS in 145 patients revealed triphasic flow pattern in the common femoral arteries in all patients except for 2 (1.38%). These patients were determined to have asymptomatic arterial stenosis. Chronic recanalized thrombus in the common femoral vein was also detected in 2 (1.38%) patients. Conclusion: Femoral artery cannulation with the U-suture technique can be successfully performed in robotic-assisted cardiac surgery, with good mid-term results.

Clinical, ultrasonographic and histological findings in varicose vein surgery

SUMMARY OBJECTIVE This study aims to correlate the demographic data, different clinical degrees of chronic venous insufficiency (CEAP), ultrasound findings of saphenofemoral junction (SFJ) reflux, and anatomopathological findings of the proximal segment of the great saphenous vein (GSV) extracted from patients with primary chronic venous insufficiency (CVI) submitted to stripping of the great saphenous vein for the treatment of lower limb varicose. METHOD This is a prospective study of 84 patients (110 limbs) who were submitted to the stripping of the great saphenous vein for the treatment of varicose veins of the lower limbs, who were evaluated for CEAP clinical classification, the presence of reflux at the SFJ with Doppler ultrasonography, and histopathological changes. We study the relationship between the histopathological findings of the proximal GSV withdrawal of patients with CVI with a normal GSV control group from cadavers. RESULTS The mean age of the patients was higher in the advanced CEAPS categories when comparing C2 (46,1 years) with C4 (55,7 years) and C5-6(66 years), as well as C3 patients (50,6 years) with C5-6 patients. The normal GSV wall thickness (mean 839,7 micrometers) was significantly lower than in the saphenous varicose vein (mean 1609,7 micrometers). The correlational analysis of reflux in SFJ with clinical classification or histopathological finding did not show statistically significant findings. CONCLUSIONS The greater the age, the greater the clinical severity of the patients. The GSV wall is thicker in patients with lower limb varicose veins, but those histopathological changes are not correlated with the disease's clinical severity or reflux in the SFJ on a Doppler ultrasound.

RESUMO OBJETIVO Este estudo tem como objetivo correlacionar os dados demográficos, os diferentes graus clínicos da insuficiência venosa crônica (Ceap), com achados ultrassonográficos de refluxo da junção safenofemoral (JSF) e os achados anatomopatológicos do segmento proximal da veia safena magna (VSM) extraído de pacientes com insuficiência venosa crônica (IVC) primária submetidos à safenectomia magna para correção de varizes dos membros inferiores. MÉTODO Estudo prospectivo de 84 pacientes e 110 membros submetidos à safenectomia magna para o tratamento de varizes de membros inferiores, correlacionando a sua classificação clínica Ceap, presença de refluxo na JSF ao ultrassom Doppler e alterações histopatológicas. Comparamos ainda os achados histopatológicos da VSM proximal retirada dos pacientes com IVC com grupo controle de VSM normal retirada de cadáveres. RESULTADOS Média de idade dos pacientes foi maior nos Ceaps avançados quando comparado Ceap C2 (46,1 anos) com C4 (55,7 anos) e C5-6 (66 anos), e pacientes C3 (50,6 anos) com C5-6. A espessura da parede da VSM normal (média de 839,7 micrômetros) foi significativamente menor do que das VSM varicosas (média de 1.609,7 micrômetros). As análises de correlação da presença do refluxo em JSF com a classificação clínica ou achado histopatológico não demostraram ser estatisticamente significativas. CONCLUSÕES Quanto maior a idade, mais avançada é a classificação clínica da IVC dos pacientes. A espessura da parede da crossa da VSM é maior nos pacientes com IVC e essas alterações não se correlacionam com a classificação clínica da doença ou com a presença de refluxo na JSF ao ultrassom Doppler.

Canalización vascular ecoguiada: Experiencia en el paciente pediátrico crítico / Ultrasound-guided vascular cannulation: Experience in critically-ill pediatric patients

Introducción. La canalización vascular central en niños presenta alta complejidad técnica y dificultades. La ecografía vascular puede facilitar este procedimiento. Objetivo. Describir las características de las canalizaciones vasculares ecoguiadas en el paciente pediátrico crítico. Población y métodos. Las variables de interés registradas prospectivamente fueron los vasos más comúnmente canalizados, su localización, la medición del diámetro/profundidad, la tasa de éxito y las complicaciones presentadas, entre otras. Resultados. En 86 pacientes pediátricos, se realizaron 124 punciones vasculares. Los accesos vasculares fueron la vena femoral (39,7%), seguida de la arteria femoral (27,2%) y la vena yugular interna (14,7%). Los vasos femorales se localizaron a una profundidad de 0,75 ± 0,25 mm con un diámetro medio de 0,31 ± 0,16 mm. La profundidad de los vasos venosos yugulares fue menor (0,64 ± 0,24 mm) y su diámetro global, mayor (0,44 ± 0,19 mm). El número medio de intentos en las canalizaciones vasculares ecoguiadas fue de 2,2 ± 1,3. La tasa de éxito fue del 79% asociada a un mayor diámetro del vaso (0,39 ± 0,20 mm vs. 0,28 ± 0,13 mm, p 0,01) y un menor número de intentos (1,90 ± 1,16 vs. 3,45 ± 1,77, p= 0,001). Las complicaciones, fueron la punción accidental de otro vaso (5,3%) y el desarrollo de un hematoma durante la punción (2,3%). Conclusiones. La canalización vascular ecoguiada en los pacientes pediátricos estudiados permite visualizar los vasos y medir su profundidad y diámetro; presenta una alta tasa de éxito y se asocia a una baja tasa de complicaciones.

Introduction. Central vascular cannulation in children is a highly complex technique and poses many difficulties. Vascular ultrasound can make this procedure easier. Objective. To describe the characteristics of ultrasound-guided vascular cannulation in critically-ill pediatric patients. Population and methods. Outcome measures prospectively recorded were vessels most frequently cannulated, their localization, the measurement of their diameter/depth, the success rate and complications developed, among others. Results. One hundred and twenty four vascular punctures were performed in 86 pediatric patients. Vascular accesses were the femoral vein (39.7%), followed by the femoral artery (27.2%) and the internal jugular vein (14.7%). Femoral vessels were localized at a depth of 0.75 ± 0.25 mm, with a mean diameter of 0.31 ± 0.16 mm. The depth of jugular vein vessels was smaller (0.64 ± 0.24 mm) and their overall diameter, larger (0.44 ± 0.19 mm). The mean number of attempts in ultrasound-guided cannulations was 2.2 ± 1.3. The success rate was 79% and was associated to a larger vessel diameter (0.39 ± 0.20 mm vs. 0.28 ± 0.13 mm, p= 0.01) and a lower number of attempts (1.90 ± 1.16 vs. 3.45 ± 1.77, p= 0.001). Complications were accidental puncture of another vessel (5.3%) and hematoma formation during puncture (2.3%). Conclusions. In the pediatric patients studied, ultrasound-guided vascular cannulation allowed vessel visualization and measurement of their depth and diameter; the success rate was high and it was associated to a low complication rate.

Trombosis focal de vena femoral común: manifestación (jjVmssMark inicial de linfoma no Hodgkin difuso de células grandes B / Focal thrombosis of common femoral vein: initial manifestation of diffuse large B cell lymphoma

Resumen La trombosis venosa profunda (TVP) es una enfermedad frecuente que afecta anualmente al 0,1-0,3% de la población general; además es una causa importante de morbimortalidad en el paciente oncológico. La TVP se produce con más frecuencia en la fase de tratamiento en la que se asocian los efectos protrombóticos del proceso neoplásico y de la quimioterapia. En un menor número de casos se identifica en el diagnóstico o incluso puede ser su primer síntoma. Una TVP focal secundaria a compresión extrínseca y desestructuración de los tejidos circundantes eleva la sospecha de un proceso maligno. Se presenta un caso de TVP focal como primomanifestación de un linfoma no Hodgkin difuso de células grandes B.

Abstract Deep venous thrombosis (DVT) is a common disease that annually affects 0.1-0.3% of the general population; It is also a significant cause of morbidity and mortality in cancer patients. DVT occurs more frequently in the treatment phase in which they are associated with the neoplastic prothrombotic process and effects of chemotherapy. In a small number of cases it is identified in the diagnosis or it may even be its first symptom. A secondary focal DVT extrinsic compression and destruction of surrounding tissue raises the suspicion of a malignant process. A case is presented of a focal DVT that was the first manifestation a non-Hodgkin's diffuse large B-cell lymphoma.