Síndrome compartimental bilateral de pierna tras posición de litotomía prolongada: presentación de un caso clínico / Bilateral leg compartment syndrome after prolonged lithotomy position: clinical case report

INTRODUCCIÓN: El síndrome compartimental es una complicación infrecuente pero severa que puede aparecer ante una posición de litotomía prolongada y el uso de perneras. OBJETIVO: Presentar un caso de síndrome compartimental bilateral tras posición de litotomía prolongada asociada con el uso de perneras. MATERIAL Y MÉTODOS: Paciente varón de 43 años sometido a una cirugía urológica en posición habitual de litotomía durante un periodo de 6 horas. A las 2 horas de finalizar la cirugía, el paciente presentó dolor intenso y endurecimiento de compartimento anterior y lateral de ambas piernas, junto con una elevación de la creatina quinasa sérica (valor inicial de 109 U/L que se elevó hasta 7.689 U/L a las 12 horas) y una imposibilidad para la flexión dorsal pasiva de ambos tobillos. El paciente no sentía dolor en el resto de los compartimentos. RESULTADOS: Ante la sospecha de un síndrome compartimental anterolateral, se realizó fasciotomía bilateral urgente, y se observó una disminución de la perfusión muscular y mejoría de la misma tras apertura de la fascia. Se realizaron curas periódicas cada 48 horas, y se observó viabilidad del tejido hasta su cierre definitivo a los 4 días. A las 2 semanas, el paciente presentó fatiga ligera para la deambulación sin ayuda, con tumefacción en el compartimento lateral de ambas piernas. A los 10 meses de evolución, el paciente caminaba sin ayuda y con función muscular completa. CONCLUSIONES: El conocimiento de la asociación del síndrome compartimental y la cirugía laparoscópica prolongada es esencial para un diagnóstico precoz y un tratamiento quirúrgico inmediato, para evitar graves secuelas. Los buenos resultados de nuestro paciente se deben a la rápida actuación, ya que normalmente se suele demorar. Para evitar su aparición o disminuir su incidencia, la posición de litotomía debería limitarse a aquellos momentos de la cirugía en los que sea imprescindible, modificando la posición de las piernas cada dos horas en caso de cirugías prolongadas, para prevenir dicha complicación.

Compartment syndrome is a rare but severe complication resulting from a prolonged lithotomy position and the use of leg loops. PURPOSE: To present a case of bilateral compartment syndrome after prolonged lithotomy position associated with the use of leg loops. METHODS: A 43-year-old man underwent urological surgery in the usual lithotomy position for a 6-hour period. Two hours after the end of the surgery, the patient presented severe pain and stiffening of the anterior and lateral compartments of both legs, elevated serum creatine kinase levels (the baseline value of 109 U/L increased to 7,689 U/L at 12 hours), and inability for passive dorsiflexion of both ankles. The patient reported no pain in the other compartments. RESULTS: Suspicion of an anterolateral compartment syndrome resulted in an urgent bilateral fasciotomy; muscle perfusion was decreased, and it improved after fascial opening. Dressings were changed every 48 hours, and tissue viability was observed until the final closure at 4 days. At two weeks, the patient presented slight fatigue when walking with no assistance, in addition to swelling in the lateral compartment of both legs. Ten months after surgery, the patient walked with no assistance and with complete muscle function. CONCLUSION: Knowledge of the association between compartment syndrome and prolonged laparoscopic surgery is essential for an early diagnosis and immediate surgical treatment to avoid serious sequelae. In our patient, the good outcomes resulted from quick action, since diagnosis is often delayed. Limiting the lithotomy position to those surgical moments in which it is essential and changing the position of the legs every 2 hours during prolonged procedures can reduce the occurrence and incidence of compartment syndrome, preventing this complication.

Insuficiência venosa crônica e uso de meia elástica de compressão graduada: uma análise sobre a adesão ao tratamento em pacientes do SUS / Chronic venous insufficiency and graduated compression stockings: analysis of public health system patients' adherence to treatment

Resumo Contexto A insuficiência venosa crônica é uma doença de alta prevalência mundial, podendo chegar a até 80% da população. Sua incidência aumenta com a idade e é mais frequente no sexo feminino. Das opções terapêuticas, destaca-se a terapia compressiva, sendo a principal o uso de meia elástica de compressão graduada, considerado o tratamento básico para a insuficiência venosa crônica independentemente da classificação clínica do paciente. Na prática clínica, o resultado da terapia é prejudicado pela não adesão ao uso da meia. Objetivos Avaliar a taxa de adesão ao uso da meia elástica de compressão graduada, assim como compreender a problemática da não aderência ao tratamento. Métodos Estudo observacional transversal, realizado entre junho de 2017 até janeiro de 2019, mediante aplicação de questionário aos pacientes em ambulatório de cirurgia vascular do Sistema Único de Saúde (SUS), em um hospital-escola, em Curitiba, no estado do Paraná (PR). Os dados foram analisados com o programa computacional IBM SPSS Statistics v.20.0. Resultados Foram analisados 240 pacientes. A média de idade foi de 57,5±12,9 (22-86); 84,2% eram do sexo feminino. Do total de pacientes analisados, 106 (44,2%) não aderiram ao uso das meias. As justificativas para o não uso foram: questão financeira, dor, desconhecimento da necessidade, calor e outras. Conclusões A taxa de adesão encontrada no presente estudo foi de 55,8%, e o principal motivo para o não uso foi a questão financeira.

Abstract Background Chronic venous insufficiency (CVI) is a pathology of great importance due to its high worldwide prevalence, affecting up to 80% of the population. Its incidence increases with age and is more frequent in females. One of the most important treatment options is compression therapy and the main method employed is wearing graduated compression stockings, which is considered the basic treatment for CVI regardless of the patient's clinical classification. In clinical practice, treatment outcomes are impaired by patients not wearing the stockings properly. Objectives To analyze the rate of adherence to wearing graduated compression stockings and to understand the problem of treatment non-adherence. Methods Cross-sectional observational study conducted from June 2017 to January 2019, based on administration of questionnaires to patients at a SUS vascular surgery clinic at a teaching hospital, in Curitiba, PR, Brazil. Data were analyzed using the IBM SPSS Statistics v.20.0 computer program. Results 240 patients were analyzed. Mean age was 57.5 ± 12.9 (22 - 86) and 84.2% of the sample were female. 106 of the 240 patients analyzed (44.2%) were non-adherent with wearing compression stockings. Reasons for not wearing the stockings were: financial; pain; ignorance of the need to wear them; heat; and others. Conclusions The adherence rate observed in the present study was 55.8% and the most prevalent reason for not wearing stockings was financial.

Stents in the femoropopliteal territory: prevalence of fractures and their consequences / Stents no território fêmoro-poplíteo: prevalência de fraturas e suas consequências

ABSTRACT Endovascular treatment for femoropopliteal arterial disease has made revascularization procedures less invasive, but the self-expanding stents used can suffer great wear in arteries with extreme mobility. Objective: to evaluate the prevalence of fractures in stents implanted in the femoropopliteal segment, to identify predisposing factors and consequences on arterial patency. Method: between March and June 2019, thirty patients previously operated for femoropopliteal obstruction underwent stent X-rays in anteroposterior and lateral views to detect fractures and Doppler to analyze arterial patency. Results: we observed 12 cases with fractures (33.3%): 1 type I (2.8%), 3 type II (8.3%), 5 type III (13.9%), 3 type IV (8.3%) and no type V. According to the TASC II we had 1 in group B (8.3%), 6 in group C (50%) and 5 in group D (41.6%) p <0.004. The number of stents per limb was 3.1 (± 1.3) in cases of fracture versus 2.3 (± 1.3) in cases without fracture (p = 0.08). The extension was 274.17mm (± 100.94) in cases of fracture and 230.83mm (± 135.44) in cases without fracture (p = 0.29). On Doppler we had: 17 patients (47.2%) without stenosis, 9 patients (25%) with stenosis> 50% and 10 patients (27.8%) with occlusion (p = 0.37). There was no correlation between fracture and arterial obstruction (p = 0.33). Conclusion: stent fractures are a frequent finding in the femoropopliteal area (33.3%), being more prevalent in cases of more advanced disease (C and D). There was no association between the finding of fracture and arterial obstruction.

RESUMO Os tratamentos endovasculares para a doença arterial obstrutiva fêmoro-poplítea tornaram os procedimentos de revascularização menos invasivos, porém os stents metálicos autoexpansíveis utilizados podem sofrer grande desgaste em artérias com extrema mobilidade. Objetivo: avaliar a prevalência de fraturas em stents implantados no segmento fêmoro-poplíteo, identificar fatores predisponentes e possíveis consequências sobre a patência arterial. Métodos: entre março a junho de 2019, trinta pacientes previamente operados por obstrução fêmoro-poplítea realizaram RX dos stents em incidências ântero-posterior e perfil para detectar fraturas e eco Doppler para analisar a patência arterial. Resultados: observamos 12 casos com fraturas (33,3%): 1 do tipo I (2,8%), 3 do tipo II (8,3%), 5 do tipo III (13,9%), 3 do tipo IV (8,3%) e nenhuma tipo V. Segundo a classificação TASC II, tivemos 1 no grupo B (8,3%), 6 no grupo C (50%) e 5 no grupo D (41,6%) p<0,004. O número de stents por membro foi de 3,1 (±1,3) nos casos de fratura contra 2,3 (±1,3) nos casos sem fratura (p = 0,08). A extensão tratada foi 274,17mm (±100,94) nos casos de fratura e 230,83mm (±135,44) nos casos sem fratura (p=0,29). No Doppler tivemos: 17 pacientes (47,2%) sem estenose, 9 pacientes (25%) com estenose>50% e 10 pacientes (27,8%) com oclusão (p=0,37). Não houve correlação entre fratura e obstrução arterial (p=0,33). Conclusão: as fraturas de stents são um achado frequente no setor fêmoro-poplíteo (33,3%) sendo mais prevalentes nos casos de doença mais avançada TASC II C e D. Não houve associação entre o achado de fratura e obstrução arterial.

A practical approach to assess leg muscle oxygenation during ramp-incremental cycle ergometry in heart failure

Heart failure is characterized by the inability of the cardiovascular system to maintain oxygen (O2) delivery (i.e., muscle blood flow in non-hypoxemic patients) to meet O2 demands. The resulting increase in fractional O2 extraction can be non-invasively tracked by deoxygenated hemoglobin concentration (deoxi-Hb) as measured by near-infrared spectroscopy (NIRS). We aimed to establish a simplified approach to extract deoxi-Hb-based indices of impaired muscle O2 delivery during rapidly-incrementing exercise in heart failure. We continuously probed the right vastus lateralis muscle with continuous-wave NIRS during a ramp-incremental cardiopulmonary exercise test in 10 patients (left ventricular ejection fraction <35%) and 10 age-matched healthy males. Deoxi-Hb is reported as % of total response (onset to peak exercise) in relation to work rate. Patients showed lower maximum exercise capacity and O2 uptake-work rate than controls (P<0.05). The deoxi-Hb response profile as a function of work rate was S-shaped in all subjects, i.e., it presented three distinct phases. Increased muscle deoxygenation in patients compared to controls was demonstrated by: i) a steeper mid-exercise deoxi-Hb-work rate slope (2.2±1.3 vs 1.0±0.3% peak/W, respectively; P<0.05), and ii) late-exercise increase in deoxi-Hb, which contrasted with stable or decreasing deoxi-Hb in all controls. Steeper deoxi-Hb-work rate slope was associated with lower peak work rate in patients (r=-0.73; P=0.01). This simplified approach to deoxi-Hb interpretation might prove useful in clinical settings to quantify impairments in O2 delivery by NIRS during ramp-incremental exercise in individual heart failure patients.

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.

Isolated plexiform neurofibroma mimicking a vascular lesion

Abstract Plexiform neurofibromas are benign tumors originating from peripheral nerve sheaths, generally associated with Neurofibromatosis Type 1 (NF1). They are diffuse, painful and sometimes locally invasive, generating cosmetic problems. This report discusses an adolescent patient who presented with an isolated, giant plexiform neurofibroma on her leg that was confused with a vascular lesion due to its clinical aspects. Once the diagnosis was confirmed by surgical biopsy, excision of the lesion was performed with improvement of the symptoms.

Membranous lipodystrophy: case report and review of the literature

Membranous lipodystrophy is a distinct type of membranocystic fat necrosis. It is associated with many local and systemic diseases, including vascular disorders. The histopathological changes which characterize this phenomenon are variably sized cysts in the fat lobules of the subcutaneous tissue, which are surrounded by eosinophilic membranes projecting into the cystic space. We report a case of secondary membranous lipodystrophy associated with both hypertension and venous insufficiency.

Tromboembolia arterial y amputación de una extremidad en un neonato posterior al síndrome de dificultad respiratoria: Caso clínico / Neonatal arterial thromboembolism and limb loss following respiratory distress syndrome: Case report

La tromboembolia en los recién nacidos es un problema grave. Los factores de riesgo más importantes son iatrogénicos, entre ellos, el uso de sondas umbilicales o vías centrales permanentes. Entre otros factores de riesgo, se incluyen la asfixia, la deshidratación, la septicemia, la cardiopatía, el síndrome de dificultad respiratoria, la coagulación intravascular diseminada, la trombofilia congénita (deficiencia de proteína C o proteína S), la diabetes mellitus materna y la transferencia pasiva de anticuerpos antifosfolípidos maternos. Los recién nacidos son más vulnerables que los adultos a presentar una trombosis debido a su menor capacidad fibrinolítica. Describimos el caso de una recién nacida de un día de vida con tromboembolia arterial en el miembro inferior; sin vía central. La tromboembolia en este caso estuvo asociada con un síndrome de dificultad respiratoria. Se realizó trombólisis; tratamiento anticoagulante y trombectomía quirúrgica. Posteriormente; se amputó el miembro inferior por debajo de la rodilla.

Thromboembolic disease in newborn infants is a serious problem. The most important risk factors are iatrogenic factors, including indwelling umbilical catheters or central catheters. Other risk factors include asphyxia, dehydration, sepsis, cardiac disease, respiratory distress syndrome (RDS), disseminated intravascular coagulation, congenital thrombophilia (i.e., protein C or protein S deficiency), maternal diabetes mellitus, and passive transfer of maternal antiphospholipid antibodies. Neonates are more vulnerable to thrombosis than adults due to their reduced fibrinolytic capability. We describe a case of a 1-day-old female newborn with arterial thromboembolism in the lower leg without a central line catheter. The thromboembolismin in this case was associated with RDS. The infant underwent thrombolysis, anticoagulation therapy, and surgical thrombectomy. The leg of the infant was subsequently amputated below the knee. The case is described here with a brief review of relevant literatures.

Técnica de ligadura subfascial mini-invasiva de venas perforantes de las piernas / Treatment of incompetent perforator leg veins by minimally invasive subfascial ligation

Perforator vein incompetence is a specific form of lower extremitiy venous insufficiency characterized by localized hyperpigmentation, venous ulceration or recurrence of varicose veins. Surgical treatment ranges from the extensive conventional open subfascial ligation to percutaneous radiofrequency or laser techniques with unknown late outcome. A minimally invasive technique of subfascial ligation through small incisions described by Queral, with acceptable results, has been successfully used and improved in recent years by our group. Details of the technique and pre-operative managment are described.

La insuficiencia de venas perforantes es una forma de insuficiencia venosa de extremidades inferiores que se manifiesta por hiperpigmentación cutánea localizada, desarrollo de úlceras venosas o recurrencia de várices previamente operadas. Su tratamiento comprende desde cirugías cruentas como la ligadura subfascial abierta a técnicas percutáneas de radiofrecuencia o láser con resultados alejados desconocidos. Dentro de las técnicas mínimamente invasivas se encuentra la cirugía de ligadura subfascial de perforantes con mini-incisiones descrita por Queral, de eficacia demostrada y que hemos realizado y perfeccionado exitosamente en los últimos años. Se describen detalles de la técnica y de la planificación pre-operatoria de pacientes con esta patología.

Análise das arteriografias de diabéticos e não diabéticos com isquemia crítica da perna / Arteriographic findings in diabetic and non-diabetic with critical limb ischemia

RESUMO OBJETIVO: Comparar características angiográficas de pacientes diabéticos e não diabéticos com isquemia crítica. MÉTODOS: Foram incluídos 161 membros inferiores de pacientes com isquemia crítica infrainguinal. Avaliaram-se as características clínicas e arteriográficas (número e presença de opacificação das artérias da perna) dos dois grupos de pacientes. A análise estatística foi realizada pelo EPI-INFO RESULTADOS: A maioria dos pacientes era categoria 5da Classificação de Rutherford e apresentava doença do território fêmoro-poplíteo. Opacificação da artéria fibular foi encontrada em 72% dos não diabéticos e em 67% dos diabéticos (p = 0,25), sendo esta a artéria mais presente em ambos os grupos. Os diabéticos apresentaram menor índice de opacificação da artéria tibial posterior na análise univariada (29% vs. 47%; p = 0,008). Na regressão logística, apenas o sexo feminino se mostrou significante para a ausência da artéria tibial posterior (OR = 2,6; p = 0,01) CONCLUSÃO: A artéria fibular foi a mais encontrada nas angiografias de diabéticos e não diabéticos com isquemia crítica. Diabéticos e não diabéticos não diferiram em relação ao padrão angiográfico da perna.

OBJECTIVE: To compare angiographic findings of diabetic and non-diabetic patients with critical limb ischemia. METHODS: We included 161 patients with infrainguinal critical limb ischemia (CLI). We evaluated the clinical and arteriographic (number and presence of opacification of leg arteries) of the two groups of patients. Statistical analysis was performed using EPI-INFO. RESULTS: Most patientswere category 5 of Rutherford's Classification and had femoropopliteal disease. Seventy-two percent of non-diabetic and 67% of diabetic had opacification of the fibular artery (p = 0.25), this is the most present artery in both groups. Diabetic patients had less opacification of the posterior tibial artery in the univariate analysis (29% vs. 47%, p = 0.008). But only female sex showed a significant risk for the absence of the posterior tibial artery in logistic regression (OR = 2.6; p = 0.01). CONCLUSION: The peroneal artery was the most frequently artery in angiograms of diabetic and non-diabetic patients with CLI. Diabetic and non-diabetic patients did not differ in angiographic findings of the leg.

[Lumbar sympathetic block for ischemic leg pain management secondary to systemic lupus erythematosus: a case report]

Ischaemic pain counts among the most difficult to treat pains in palliative care. Ischemic pain is frequently severe, and usually resistant to available analgesics. Treatment of this condition is difficult, especially when the condition is inoperable. A 36-year-old woman with the diagnosis of systemic lupus erythematosus with severe ischemic pain in the lower leg due to vascular problems presented to Akhtar Hospital. The patient was arranged for lumbar sympathetic block which was performed in two stages with one week interval. In the procedure, a long needle with No.22 gauge and the length of 15 cm was used. Under view of fluoroscopy guide, 10 cc marcaine 0.125% was injected. In the second stage, 5 cc of marcaine 0.25% and 5 cc of phenol 0.6% were used. Pain improvement was observed immediately after neurolytic lumbar sympathetic block. Three-month follow up period revealed improvement of quality of life. Lumbar sympathetic block is considered as a safe and useful technique. Clinically, the technique is effective for pain relief in patients who develop lower leg pain due to vasculitis.

Increased incidence of abnormal reflux flow in lower extremity veins of cirrhotic patients by doppler ultrasonography

To determine incidence of abnormal reflux flow [ARF] in legs of cirrhotic patients by Doppler ultrasonography [DUS]. We prospectively studied 100 patients and 56 controls from the Faculty of Medicine, Eskisehir Osmangazi University Eskisehir, Turkey, between January 2010 and December 2011. We classified the legs according to the Clinical Etiology Anatomy Pathophysiology [CEAP] scores. Lower extremity superficial and deep veins were examined in supine position by DUS for ARF. Reflux flows more than 1000 msec were considered as abnormal. Abnormal reflux flow was classified in 3 categories as superficial [SARF], deep [DARF], and SARF and/or DARF [ARF]. We also performed abdominal DUS to depict anterior abdominal collateral and paraumbilical vein. Statistical analysis was carried out by using analysis of variance with Tukey test, t-test, and correlation coefficient analysis. Percentages of SARF in patients were 56%, DARF 52%, and ARF 58%. Correlation analysis showed association between SARF or DARF or ARF and cirrhosis [p=0.002, p=0.000, p=0.001]. Patients were distributed within CEAP 1 to CEAP 4. There was an association between SARF or DARF and CEAP 1 [p=0.007, p=0.000] or CEAP 2 [p=0.004, p=0.041] or CEAP 4 [p=0.022, p=0.90]. We showed no correlation between CEAP 3 and SARF or DARF. There were also correlation between paraumbilical vein and SARF [p=0.015]. Cirrhotic patients increased incidence of ARF at lower extremity veins and CEAP classification creates and provides essential information

Diabetes-related lower-extremity amputation incidence and risk factors: a prospective seven-year study in Costa Rica / Incidencia y factores de riesgo de la amputación de extremidades inferiores relacionada con la diabetes: estudio prospectivo de siete años en Costa Rica

Objective. To analyze the incidence and determinants of lower-extremity amputation(LEA) in people with diabetes in a low-income community in Costa Rica.Methods. Data on LEA incidence were collected during a seven-year follow-up (2001–2007) in a diabetes patient cohort (n = 572). Risk factors were analyzed using the Coxproportional hazards regression model and baseline variables from the year 2000 (sociodemographiccharacteristics, comorbidity, metabolic control, treatment, and chronic microvascularcomplications).Results. LEA incidence was 6.02 per 1 000 person-years (8.65 in men and 4.50 in women).Known risk factors (sex, years of diabetes, elevated glycated hemoglobin [HbA1c], retinopathy,insulin therapy, and prior amputation) were highly significant.Conclusions. Those most likely to undergo LEA among Costa Rican diabetic patients weremen with 10 or more years of diabetes and average HbA1c ≥ 8% who used insulin and haddiabetic retinopathy. Patients on insulin therapy were at greatest risk, especially those with aprevious amputation. Diabetic patients with the above-mentioned profile should be consideredto be at very high risk of LEA and followed closely by the health care system.

Objetivo. Analizar la incidencia y los determinantes de la amputación deextremidades inferiores (AEI) en personas diabéticas de una comunidad con bajosingresos de Costa Rica.Métodos. Se recopilaron datos sobre la incidencia de la AEI durante un período deseguimiento de siete años (del 2001 al 2007) en una cohorte de pacientes diabéticos(n = 572). Se analizaron los factores de riesgo usando el modelo de regresión de Coxde riesgos proporcionales y los valores de referencia del año 2000 de las variables(características sociodemográficas, comorbilidad, control metabólico, tratamiento ycomplicaciones microvasculares crónicas).Resultados. La incidencia de la AEI fue de 6,02 por 1 000 personas-año (8,65 envarones y 4,50 en mujeres). Los factores de riesgo conocidos (sexo, años de evoluciónde la diabetes, glucohemoglobina [HbA1c] elevada, retinopatía, tratamiento coninsulina y amputación previa) fueron muy significativos.Conclusiones. Los pacientes diabéticos costarricenses con mayor probabilidad desufrir una AEI fueron los varones con 10 o más años de evolución de la diabetesy un promedio de HbA1c ≥ 8% que eran tratados con insulina y padecían unaretinopatía diabética. Los pacientes en tratamiento con insulina presentaban el mayorriesgo, especialmente los que habían sufrido una amputación anterior. Los pacientesdiabéticos con el perfil descrito anteriormente deben considerarse como de riesgomuy elevado de AEI y deben ser seguidos de cerca por el sistema de atención desalud.

Tratamiento endovascular de lesiones de arteria femoral superficial, TASC II B-C mediante stents de nitinol autoexpandibles extra largos (> 120 mm). Evaluación de la permeabilidad a los 6, 12, 24 y 36 meses post implante. / Tratamento endovascular de lesões da artéria femoral superficial, TASC II B-C com o uso de stents de nitinol auto-expansíveis extra longos (> 120mm). Avaliação da permeabilidade após 6, 12, 24 e 36 meses pós implante. / Endovascular treatment of TASC II B-C lesions of the superficial femoral artery with ultra long self expandable nitinol stents (> 120 mm). Assessment of patency at 6, 12, 24 and 36 months post-stenting

Objetivos: evaluación de la permeabilidad de los stents de Nitinol autoexpandibles extra largos(> 120 mm de longitud) en lesiones de arteria femoral superficial TASC II B-C, a los 6, 12, 24 y 36 meses post implante.Pacientes y Métodos: Entre junio de 2007 y diciembre de 2008, fueron tratados 7 miembros inferiores en 6 pacientes con lesiones de arteria femoral superficial tipo TASC II B-C mediante stents extra largos auto expandibles. Utilizamos stents autoexpandibles de Nitinol de 120-140 mm largo (Large SMART CONTROL) (Cordis). Utilizamos la vía percutánea ipsilateral anterógrada y, en aquellos pacientes que presentaron enfermedad de la cámara femoral, realizamos tratamiento hibrido: endarterectomía femoral, angioplastia con balón y colocación de stent. Se realizó elseguimiento mediante Ecodoppler y Rx de miembro inferior a los 6, 12, 24 y 36 meses post implante. Resultados: Se intervino a 5 pacientes del sexo femenino (84%) con un promedio de edad de 74 años +/- 5; 1 paciente de sexo masculino (16%) cuya edad fue de 60 años. 3 procedimientos fueron por vía percutánea ipsilateral anterógrada. Se realizaron 4 procedimientos híbridos (endarterectomía cámara femoral, angioplastia con balón y colocación de stent). La permeabilidad inicial fue del 100%, permeabilidad a los 6 meses: 100% de los casos, permeabilidad a los 12 meses: 86% de los casos, permeabilidad a los 24 meses: 86% de los casos con detección de Reestenosisen una paciente del 60%, siendo asintomática, permeabilidad a los 36 meses: 72 % de los casos. No se observaron fracturas de stent durante el estudio. Conclusiones: El stent largo de (> 120 mm longitud) es un buen instrumento para el tratamientode lesiones tipo TASC II B-C, comparables con la cirugía convencional, los cirujanos vascularesdeben conocer y aplicar todas las técnicas disponibles (cirugía, bioingeniería, endovascular, etc.) al tratar enfermedad arterial periférica encontrando la mejor opción para cada paciente...

Objetivo: avaliaçãó da permeabilidade dos stents de Nitinol auto expansíveis extra longos (> 120 mm de longitude) em lesões da artéria femoral superficial TASC II B-C, após 6, 12, 24 e 36 mesespós implante. Pacientes e Métodos: Entre junho de 2007 e dezembro de 2008, foram tratados 7 membrosinferiores em 6 pacientes com lesões da artéria femoral superficial tipo TASC II B-C com o uso de stents extra longos auto expansíveis. Utilizamos stents auto expansíveis de Nitinol de 120-140mm de comprimento (Large SMART CONTROL) (Cordis). Utilizamos a via percutânea ipsilateral anterógrada e, nos pacientes que apresentaram problemas na câmara femoral, realizamos um tratamento híbrido: endarterectomia femoral, angioplastia com balão e colocação de stent. Oseguimento foi realizado com a utilização de Ecodoppler e Rx de membro inferior após 6, 12, 24 e 36 meses pós implante. Resultados: Dos pacientes tratados, 5 eram do sexo feminino (84%) com uma média de idade de 74 anos +/- 5; 1 paciente do sexo masculino (16%) de 60 anos de idade. Com relação aos procedimentos, 3 foram por via percutãnea ipsilateral anterógrada. Foram realizados 4 procedimentos híbridos (endarterectomia câmara femoral, angioplastia com balão e colocação de stent). A permeabilidade inicial foi de 100%, após 6 meses, também de 100%, após 12 meses a permeabilidadefoi de 86% e 24 meses depois, de 86% com detecção de Reestenosis em uma paciente em 60%, sendo assintomática,apresentando uma permeabilidade após 36 meses de 72%. Não foram observadas fraturas de stent durante o estudo realizado. Conclusões: O stent longo de (> 120 mm de comp.) é um bom instrumento para o tratamentode lesões tipo TASC II B-C, comparáveis com a cirurgia convencional, os cirurgiões vasculares devem conhecer e aplicar todas as técnicas disponíveis (cirurgia, bioengenharia, endovascular, etc.) no tratamento da doença arterial periférica, encontrando a melhor opção para cada paciente...

Objetives: Evaluation of self-expanding large nitinol (> 120mm) stents patency in the treatments of TASC II B-C of SFA lesions at 6, 12 , 24 and 36 months after implantation. Patients and Methods: Between June 2007 to December 2008, we have treated 7 legs in 6 patients with TASC II B-C of Superficial Femoral Artery lesions with large nitinol stent, SMART (Cordis). The procedures was with percutaneous ipsilateral antegrade approach and when the patients had femoral common disease had made hybrid approach (open femoral endarterectomy+ balloon angioplasty & stent placement). We used nitinol stents of 120-140 mm large (Large SMART CONTROL) ( Cordis). The follow-up of patency was studied with Dupplex Scan and RX of the legs at 6, 12, 24 and 36 months after the initial treatment.Results: 5 ( five) Female patients (84%) mean age 74 years +/- 5; 1 (one) Male patient (16%) mean age 60 years. 3 procedures was with percutaneous ipsilateral antegrade approach. 4 was hybrid approach ( open femoral endarterectomy + balloon angioplasty & stent placement). Initial patency was of 100%, Restenosis in one case (14%) of 60% asintomatyc patient at 24 months and distal to stent placement; Ocluded one case (14%) at 12 month (man with reestenosiscarotid stent to). Don´t observed stent fracture in this study. Conclusions: Large Nitinol stents (> 120 mm length) are a good instrument to the treatment of superficial artery lesion with a comparable patency with surgery approach in lesions TASC II B-C. Vascular Surgeons needs to learn and use all of the technics (conventional surgery, Bio Ingeneering, Endovascular) to treat periphereal arterial disease and found the best options for each patients...

Descripción anatómica de la irrigación del colgajo sural a pedículo distal en piezas cadavéricas / Anatomical description of the blood supply of the distally based sural flap in eight lower limbs

Background: The distally based sural fasciomyocutaneous flap is widely used in the coverage of deep soft tissue defects on the distal third of lower limbs. Aim: To perform a morphometric description of the perforating arteries that supplies the flap. Material and Methods: We used eight lower limbs from amputations performed above the knee. The limbs were injected through the popliteal artery with red colored latex. After the injection, the limbs were dissected to obtain a distally based sural fasciomyocutaneous flap. Once the fasciomyocutaneous island was obtained, the flap was elevated dissecting its pedicle. Once the whole flap was dissected, a morphometric registry of the lateral and medial perforating arteries was performed. The pivot point for the flap was set 5 cm above the upper border of the lateral malleolus. The distance between the upper border of the lateral malleolus and the emergence of each perforating artery was measured. Results: The sural nerve was identified in all eight dissections. A perineural plexus was the source of the blood supply of the flap, in three of the eight dissections. In two dissections, three sural arteries were identified (medial, median and lateral). The lateral sural artery was identified in two dissections and the medial and lateral arteries in one. Three to six perforating arteries were identified in the medial part of the pedicle and four to five perforating arteries in the lateral part of the pedicle. Conclusions: The distribution of the sural artery along the flap's pedicle is very variable. The most common distribution in these dissections was in the form of a perineural plexus. Considering the distance from the lateral malleolus to the emergence of the perforating arteries, the pivot point of the flap, should be set approximately at 5.5 centimeters above the lateral malleolus.

El colgajo sural fasciomiocutáneo es ampliamente utilizado en la reparación de defectos profundos de tejidos blandos del miembro inferior distal. Este estudio describe su base anatómica mediante la morfometría de las arterias perforantes en una muestra de nuestra población chilena. Material y Método: Se utilizaron 8 miembros inferiores de amputaciones supracondileas. Previa repleción con látex coloreado vía poplítea, se procedió a disecar los miembros inferiores para así obtener un colgajo fasciomiocutáneo sural de pedículo distal. Una vez obtenida la isla, se procedió a elevar el colgajo y disecar su pedículo. Luego se realizó la mor-fometría de las arterias perforantes tanto por lateral como por medial al pedículo, desde el punto pívot definido a 5 cm cefálico al maléolo lateral, hasta la base de la isla fasciomiocutánea. Se describió la distribución de la irrigación y se realizó registro fotográfico de los hallazgos. Resultados: El paquete vasculonervioso sural con un nervio fue identificado en todas las disecciones. La morfología arterial predominante fue la distribución como plexo perineural. Se reconocen tres arterias surales (lateral, mediana y medial). Fueron identificadas 3 a 6 perforantes hacia medial y 4 a 5 hacia lateral del pedículo. Conclusiones: La distribución de la arteria sural es variable y en la mayoría de los casos se presenta como plexo perineural. Dados los hallazgos de las perforantes, consideramos que el punto de giro del colgajo se encuentra aproximadamente a 5,5 cm del maleolo lateral, lo cual coincide con el punto ideal para la viabilidad del colgajo informado en otras series.

Limitação funcional e claudicação intermitente: impacto das medidas de pressão arterial / Functional limitation and intermittent claudication: impact of blood pressure measurements

FUNDAMENTO: A hipertensão arterial é importante fator de risco para Doença Arterial Obstrutiva Periférica dos Membros Inferiores (DAOMI). Entretanto, a correlação entre pressão arterial e Pressão de Pulso (PP) com a gravidade da DAOMI e o prejuízo funcional decorrente dessa doença ainda não está bem estabelecida na população brasileira. OBJETIVO: Verificar se há correlação entre pressão arterial, PP, gravidade da DAOMI e capacidade funcional de pacientes com DAOMI sintomática. MÉTODOS: FORAM avaliados 65 pacientes (62,2 ± 8,1 anos; 56,9 por cento do sexo masculino), divididos em dois grupos: pressão arterial normal (A) e elevada (B). A gravidade da DAOMI foi avaliada por meio do Índice Tornozelo-Braquial (ITB) e a capacidade funcional, pelas distâncias total e livre de dor percorridas em teste de marcha. RESULTADOS: O grupo A foi constituído por 17 (26,1 por cento) pacientes. A Pressão Arterial Sistólica (PAS), diastólica e a PP foram, respectivamente, 125,4 ± 11,7; 74,5 ± 9,1 e 50,9 ±10,0 mmHg, para o grupo A, e 160,7 ± 19,6; 90,0 ± 12,2 e 70,7 ± 20,2 mmHg, para o grupo B. O ITB foi significativamente menor no grupo B (0,66 ± 0,12 vs 0,57 ± 0,13, p < 0,05). PAS e PP correlacionaram-se com a gravidade da DAOMI e com as distâncias percorridas em teste de marcha. Pacientes com PP > 40 mmHg percorreram menores distâncias. CONCLUSÃO: A PAS e a PP correlacionaram-se de forma significativa com as distâncias percorridas em teste de marcha, sugerindo que sejam marcardores clínicos da limitação da capacidade funcional em pacientes com DAOMI sintomática.

BACKGROUND: Arterial hypertension is an important risk factor for Lower-Limb Occlusive Arterial Disease (LLOAD). However, the correlation between blood pressure and pulse pressure (PP) with LLOAD severity and functional impairment resulting from this disease is not well established in the Brazilian population. OBJECTIVE: To verify whether there is a correlation between blood pressure, PP, LLOAD severity and functional capacity in patients with symptomatic LLOAD. METHODS: A total of 65 patients (62.2 + 8.1 years, 56.9 percent males) were evaluated. They were divided into two groups: normal (A) and high (B) blood pressure. LLOAD severity was assessed using the ankle-brachial index (ABI) and functional capacity by the total and pain-free walking distance at the 6-minute walking test (6MWT). RESULTS: Group A consisted of 17 (26.1 percent) patients. The systolic (SBP), diastolic blood pressure (DBP), and PP were, respectively, 125.4 ±11.7, 74.5 ± 9.1 and 50.9 ± 10.0 mmHg in group A and 160.7 ± 19.6, 90.0 ± 12.2 and 70.7 ± 20.2 mmHg in group B. The ABI was significantly lower in group B (0.66 ± 0.12 vs. 0.57 ± 0.13, p <0.05). SBP and PP correlated with LLOAD severity and the distances walked at the 6MWT. Patients with PP > 40 mmHg walked shorter distances. CONCLUSION: SBP and PP significantly correlated with the distances walked in the 6MWT, suggesting they are clinical markers of functional capacity impairment in patients with symptomatic LLOAD.

Risk Factors and Features of Critically Ill Patients with Deep Vein Thrombosis in Lower Extremities

PURPOSE: The purpose of this study was to identify the features, risk scores and risk factors for deep vein thrombosis in critically ill patients who developed deep vein thrombosis in their lower extremities. METHODS: The participants in this prospective descriptive study were 175 adult patients who did not receive any prophylactic medication or mechanical therapy during their admission in the intensive care unit. RESULTS: The mean age was 62.24 (+/-17.28) years. Men made up 54.9% of the participating patients. There were significant differences in age, body mass index, and leg swelling between patients who developed deep vein thrombosis and those who did not have deep vein thrombosis. The mean risk score was 6.71(+/-2.94) and they had on average 4.01(+/-1.35) risk factors. In the multiple logistic regression, body mass index (odds ratio=1.14) and leg swelling (odds ratio=6.05) were significant predictors of deep vein thrombosis. CONCLUSION: Most critically ill patients are in the potentially high risk group for deep vein thrombosis. However, patients who are elderly, obese or have leg edema should be closely assessed and more than one type of active prophylactic intervention should be provided.

Nuevo enfoque para el tratamiento de las causas de ateroembolia / New approach in the treatment of the causes of ateroembolism

La ateroembolia es una entidad poco conocida y cuyo pronóstico es sombrío, especialmente en aquellos cuadros de ateroembolia diseminada, pero también en casos de ateroembolia distal que provoca un síndrome inflamatorio de respuesta sistémica. Durante 14 años recopilamos 31 casos de ateroembolia, 5 de ellas postoperatorias y 26 casos con orígenes distintos: 20 debido a aorta Shaggy y 6 a otras causas. De las 20 con aorta Shaggy, 10 presentaban ateroembolia. 22 de los 26 casos no iatrogénicos fueron tratados por vía endovascular, con una mortalidad del 9%. De acuerdo a nuestras observaciones, comentamos nuestra conducta y las variaciones en el tratamiento, proponiendo una clasificación que contemple los casos asintomáticos para el tratamiento precoz de estas lesiones aórticas, antes de producir complicaciones severas por ateroembolias o síndromes isquémicos de los miembros inferiores. Asimismo, comentamos aquellos trucos que aprendimos con la observación de los distintos casos reseñados.

A ateroembolia é uma entidade pouco conhecida e cujo prognóstico é sombrio, especialmente em quadros de ateroembolia disseminada, mas que também ocorre em casos de ateroembolia distal, o que provoca uma síndrome inflamatória de resposta sistêmica. Durante 14 anos recolhemos 31 casos de ateroembolia. 5 deles, postoperatórias e 26 casos com origens diferentes: 20 devido à aorta Shaggy e 6 por outras causas. Das 20 com aorta Shaggy, 10 apresentavam ateroembolia. 22 dos 26 casos não iatrogênicos foram tratados via endovascular, com uma mortalidade de 9%. De acordo com as nossas observações, comentamos as condutas e variações no tratamento, propondo uma classificação que inclua os casos assintomáticos para o tratamento precoce destas lesões aórticas, antes de produzir complicações severas por ateroembolias ou síndromes isquêmicos dos miembros inferiores. Comentamos os truques que aprendemos com a observação dos diferentes casos selecionados.

Ateroembolism is not a very well known entity and its prognosis is poor, especially in cases of disseminated ateroembolism, and also in cases of distal ateroembolism which causes aninflammatory syndrome of systemic response. 31 cases of ateroembolism were registered during 14 years, 5 were post-surgical and 26 due to different etiologies: 20 due to shaggy aorta and 6 due to other reasons. Of the 20 cases with shaggy aorta, 10 presented ateroembolism. 22 of the 26 non-iatrogenic cases were treated with the endovascular approach with a 9% mortality. According to our observations, we discussed our approach and treatment options, suggesting a classification which includes asymptomatic cases for early treatment of these aortic lesions, before they induce severe ateroembolic complications or lower limb ischemic syndromes. Likewise, we discuss some tips learnt during the observation of the different cases commented.

Emergency autologous vein graft reconstruction after using a vascular closure device / Reconstrução de emergência de enxerto autólogo de veia após uso de dispositivo de fechamento vascular

An emergency operation for access related acute critical limb ischemia with signs of infection is described. Inguinal femoral reconstruction was performed with a bifurcated graft constructed from the ipsilateral saphenous vein.

Uma operação de emergência relacionada à isquemia aguda com sinais de infecção é descrita. Reconstrução femoral inguinal foi realizada com um enxerto bifurcado feito a partir da veia safena ipsilateral.