Tromboprofilaxia na cirurgia de varizes dos membros inferiores no Brasil / Thromboprophylaxis in lower limb varicose vein surgery in Brazil

Resumo Contexto Apesar de todo o investimento na profilaxia primária do tromboembolismo venoso (TEV) em pacientes cirúrgicos nos últimos anos, ainda não existem diretrizes específicas para aqueles que serão submetidos a procedimentos para tratamento de varizes de membros inferiores. Objetivos Avaliar o perfil de conduta de profilaxia do TEV pelos cirurgiões vasculares brasileiros para procedimentos de tratamento de varizes de membros inferiores. Métodos Pesquisa de levantamento por envio de questionário eletrônico a cirurgiões vasculares brasileiros. Os respondentes foram divididos entre os que realizam tratamento de veias safenas por cirurgia convencional e os que realizam termoablação para fim de comparação entre os grupos. Resultados Entre os 765 respondentes, o tratamento de escolha das veias safenas foi a cirurgia convencional para 405 (53%), espuma ecoguiada para 44 (6%) e termoablação (endolaser ou radiofrequência) para 199 (26%). Os cirurgiões que realizam termoablação prescrevem mais farmacoprofilaxia após o procedimento que aqueles que preferem cirurgia convencional (67/199, 34% vs. 112/405, 28%; p = 0,002). O grupo termoablação estratifica o paciente quanto ao risco de TEV com mais frequência que o grupo cirurgia convencional (102/199, 51% vs. 179/405, 44%; p =0,004). Ambos os grupos usam mais frequentemente enoxaparina como medicação para profilaxia, porém o grupo termoablação usa mais anticoagulantes orais diretos proporcionalmente que o grupo cirurgia convencional (26% vs. 10%, p < 0,001). Conclusões Cirurgiões vasculares brasileiros que fizeram o tratamento de veias safenas por termoablação prescrevem farmacoprofilaxia com maior frequência e por um período mais prolongado do que os que realizaram o tratamento por cirurgia convencional.

Abstract Background Despite all the investment in primary venous thromboembolism (VTE) prophylaxis for surgical patients in recent years, there are still no specific guidelines for those who undergo procedures to treat lower limb varicose veins. Objectives To evaluate the profile of VTE prophylaxis practices among Brazilian vascular surgeons conducting lower limb varicose vein procedures. Methods Survey design, sending an electronic questionnaire to Brazilian vascular surgeons. Respondents were divided between those who perform saphenous vein treatment with conventional surgery and those who perform thermoablation for the purpose of comparison between groups. Results Of 765 respondents, 405 (53%) treat saphenous veins with conventional surgery for, 44 (6%) with foam, and 199 (26%) with thermoablation (endolaser or radiofrequency). Surgeons who perform thermoablation prescribed more pharmacoprophylaxis after varicose vein surgery than those who perform conventional surgery (67/199, 34% vs. 112/405, 28%; p = 0.002). The thermoablation group stratifies patients for thromboembolism risk more frequently than the conventional surgery group (102/199, 51% vs. 179/405, 44%; p = 0.004). Both groups use enoxaparin as the most frequent drug for prophylaxis, but the thermoablation group uses proportionally more direct oral anticoagulants than the conventional surgery group (26% vs. 10%, p<0.001). Conclusions Brazilian vascular surgeons who perform saphenous vein treatment by thermoablation prescribe pharmacoprophylaxis more frequently and for a longer period than those who use conventional surgery.

Varizes pulsáteis simulando aneurisma de artéria femoral: relato de caso / Pulsatile varicose veins simulating femoral artery aneurysm: case report

Resumo A regurgitação tricúspide severa é citada como fator associado ao desenvolvimento ou à recidiva de varizes em membros inferiores as quais podem, retrogradamente, apresentar um fluxo pulsátil. O diagnóstico etiológico diferencial desse achado ultrassonográfico deve ser feito com a pesquisa de fístulas arteriovenosas, tendo em vista as diferentes formas de tratamento. Dada a complexidade do estado geral dos pacientes com regurgitação tricúspide, a escolha do tratamento das varizes pulsáteis deve ser individualizada, fruto de uma avaliação multidisciplinar. Fazem parte do arsenal terapêutico todas as técnicas habitualmente empregadas no tratamento de varizes, bem como a associações entre elas a serem escolhidas levando-se em conta a gravidade das manifestações clínicas e o risco cardiovascular envolvido. Relatamos um caso de varizes pulsáteis secundárias a regurgitação tricúspide, diagnosticado durante a suspeita primária de aneurisma de artéria femoral em paciente de 73 anos, com a classificação clínica da doença venosa (CEAP) 4a, oligossintomática, tratada com medidas posturais e elastocompressão.

Abstract Severe tricuspid regurgitation is mentioned as a factor associated with development or recurrence of varicose veins in the lower limbs and may present with retrograde pulsatile flow. Differential etiological diagnosis of this ultrasound finding must include investigation of arteriovenous fistulas, since the treatment methods are different. Given the complexity of the general condition of patients with tricuspid regurgitation, treatment for pulsatile varices should be chosen on a case-by-case basis after multidisciplinary evaluation. All of the techniques commonly used to treat varicose veins are part of the therapeutic arsenal, as well as combinations of them, taking into account the severity of clinical manifestations and the cardiovascular risk involved. We report a case of pulsatile varices secondary to tricuspid regurgitation diagnosed when investigating a primary suspicion of femoral artery aneurysm in a 73-year-old patient, CEAP 4a, oligosymptomatic, who was treated with postural measures and elastic compression.

Syndrome de Klippel-Trenaunay du noir africain : particularités cliniques et thérapeutiques à propos d'un cas

Les auteurs rapportent un cas d'un syndrome de Klippel­Trenaunayrévélé par des malformations variqueuses systématisées et une ostéodystrophie avec un reflux ostial important du membre inférieur droit au CHU de Bouaké. La chirurgie classique a consisté à un éveinage étendu associé à une crossectomie droite. L'examen histologique des lacis veineux était favorable à l'existence d'un angiome. Les suites opératoires ont été simples. Après un recul de 14 mois, le patient présente une myalgie intermittente survenant à l'effort de marche. Cette observation pose le problème de l'évolution postopératoire des varices congénitales

Evaluation of liquid or foam sclerotherapy in small varicose veins (ceap c1) with venous clinical severity score

SUMMARY OBJECTIVE: We aimed to evaluate the efficacy of liquid or foam sclerotherapy of varicose veins using venous clinical severity scores and possible complications. METHODS: A total of 318 patients (268 females, 50 males) who were treated with liquid or foam sclerotherapy between January 2012 and December 2012 were included in this study. RESULTS: Skin necrosis was observed in only 6 patients (1. 8%), thrombophlebitis in 10 patients (3. 1%), and hyperpigmentation in 18 patients (5. 6%) in this study group. The mean venous clinical severity score was calculated as: pain score, 1. 23 ± 0.88; varicose vein score,1.85 ± 0. 8; edema score, 0.64 ± 0.77). Pain and edema decreased at the control examination, 1 month after completion of sclerotherapy sessions. Varicose veins completely disappeared after sclerotherapy. While the decrease in edema in the foam sclerotherapy group was significantly less (P<0.001), the decline in pain showed an increasing trend (P=0.069). While skin necrosis did not develop after foam sclerotherapy, rates of pigmentation and local thrombophlebitis were similar (P>0.05). CONCLUSION: In conclusion, we observed that both sclerotherapy methods are effective with a low rate of complications, alleviating the complaints of patients with small varicose veins, and providing considerable improvement in venous clinical severity scores.

RESUMO OBJETIVO: Nosso objetivo foi avaliar a eficácia de líquido ou espuma na escleroterapia de varizes por meio de escores de gravidade clínica venosa e possíveis complicações. MÉTODOS: Um total de 318 pacientes (268 do sexo feminino, 50 do sexo masculino) tratados com escleroterapia com espuma ou líquido entre janeiro de 2012 e dezembro de 2012 foi incluído neste estudo. RESULTADOS: Necrose da pele foi observada em apenas seis pacientes (1,8%), tromboflebite em dez pacientes (3,1%) e hiperpigmentação em 18 pacientes (5,6%) neste grupo de estudo. A média do escore de gravidade clínica venosa foi calculado como: dor pontuação 1,23±0,88, veia varicosa pontuação 1,85±0,8, edema pontuação 0,64±0,77. Dor e edema reduzido no exame de controle um mês após a conclusão das sessões de escleroterapia. Varizes desapareceram completamente após a escleroterapia. Enquanto a diminuição do edema no grupo de escleroterapia com espuma foi significativamente menor (P<0,001), o decréscimo do nível de dor mostrou uma tendência a ser maior (P=0,069). Ainda que necrose da pele não tenha se desenvolvido após escleroterapia com espuma, as taxas de pigmentação e tromboflebite local foram semelhantes (P>0,05). CONCLUSÃO: Observou-se que ambos os métodos de escleroterapia são eficazes, com baixa taxa de complicações, aliviando as queixas de pacientes com varizes pequenas, e proporcionando uma melhora considerável nos escores de gravidade clínica venosa.

Influence of prevalent occupational position during working day on occupational lower limb edema / Influência da postura prevalente de trabalho no edema ocupacional dos membros inferiores

BACKGROUND: The lower limb edema observed in normal people at the end of their working days can vary in intensity and frequency depending on the predominant working positions required to perform different jobs. OBJECTIVES: To compare lower limb volumes of volunteers allocated to three study groups, depending on the predominant positions in which they work. METHODS: Volumetric assessments were conducted of both lower limbs of 51 people free from vascular disease, allocated to three groups of 17 individuals each by predominant working position: sitting, static standing or alternating between the two. Volumes were measured at the start and at the end of the working day and the differences in volumes were calculated for each group. Means and frequencies were compared using appropriate inferential statistics and correlation coefficients were calculated. RESULTS: The groups were homogenous in terms of sex distribution, age, skin color and BMI. The volumetric data from measurements taken before starting work revealed significant differences between all three groups. Volunteers who predominantly worked sitting down had largest volumes, followed by those who remained standing for long periods and then those who varied between these positions. The frequency of lower limb volume increase > 100 mL was significantly higher in the group of people who worked sitting down and maintained this position for long periods. CONCLUSIONS: Postural edema is more common among people who work sitting down for long periods, among whom it appears that there is a cumulative effect from the position, since they exhibit larger lower limb volumes at the start of the day.

CONTEXTO: O edema de membros inferiores (MMII) de indivíduos normais, que se observa ao final da jornada de trabalho, pode ser mais intenso e frequente conforme a postura laboral prevalente no exercício da profissão. OBJETIVOS: Comparar os volumes dos MMII de indivíduos alocados em três grupos, conforme a postura laboral prevalente adotada ao longo do dia trabalho.MÉTODOS: Realizadas avaliações volumétricas de ambos os MMII de 51 indivíduos sem doença vascular, que foram alocados em três grupos de 17 indivíduos, considerando a postura prevalente: sentada, ortostática estática e alternada. As volumetrias foram realizadas no início e no término do dia trabalhado, e calculou-se a diferença dos volumes aferidos em cada grupo. Foram utilizadas as estatísticas inferenciais adequadas para comparações de médias e de frequências, e para determinação de coeficientes de correlação.RESULTADOS: Os grupos se mostraram homogêneos em relação a gênero, idade, grupo étnico e IMC. Dados das volumetrias realizadas no início do dia revelaram diferenças significativas entre os três grupos, indicando maiores volumes em indivíduos que trabalham predominantemente sentados, seguidos daqueles que trabalham em pé e dos que alternam essas posições. A frequência de MMII com aumento de volume > 100 mL foi significativamente maior no grupo dos que trabalham sentados, adotando essa posição por longo tempo.CONCLUSÕES: O edema postural é mais frequente naqueles que trabalham sentados por longo tempo, nos quais parece ocorrer, inclusive, efeito cumulativo dessa postura, já que apresentam volumes significativamente maiores já ao início do dia.

Is vein damage the only cause of clinical signs of lower limb chronic venous insufficiency? / É a lesão venosa a única responsável pela clínica da insuficiência venosa crônica dos membros inferiores?

Background: Venous insufficiency is a very prevalent disease. Some decades ago a group of patients was identified that had symptoms of venous insufficiency, but no visible anatomic abnormalities. Studies showed that this subset had reduced venous tone, and their condition became known as hypotonic phlebopathy. Objective: To investigate prevalence, age group and variations in body mass index (BMI) among patients with hypotonic phlebopathy. Methodology: A total of 1,960 limbs were examined in 1,017 patients who had been referred for complaints compatible with venous insufficiency. Patients with BMI ≥ 30 were defined as obese. The patients were examined using color Doppler ultrasonography to detect presence or absence of reflux in veins of the lower limbs and were then distributed into two groups as follows: patients with CEAP ≤ 1 and no reflux, diagnosed with hypotonic phlebopathy; or patients with CEAP ≥ 2 and reflux. Results: The study sample comprised 89.7% women and 10.3% men with a mean age of 44.9 years. Hypotonic phlebopathy was more common among the women (p = 0.0001). Obese women were more likely than women who were not obese to have venous symptom etiology involving trunk lesions (p = 0.0017). Among the men, obesity was unrelated to etiology of symptoms (p = 0.5991). Symptomology was more likely to be related to trunk vein damage among older age groups than among younger age groups (p-valor <0.0001). Conclusions: Hypotonic phlebopathy was very prevalent, particularly among young women who were not obese...

Contexto: A insuficiência venosa é uma doença muito prevalente. Há algumas décadas, evidenciou-se a existência de um grupo que, embora apresentasse sintomas de insuficiência venosa, não possuía alterações anatômicas visíveis. Estudos mostraram redução no tônus venoso nesses indivíduos, denominando-os portadores de flebopatia hipotônica. Objetivo: Estudar a prevalência, a faixa etária e as variações do índice de massa corporal (IMC) em pacientes portadores de flebopatia hipotônica. Metodologia: Foram examinados 1.960 membros de 1.017 pacientes, devido a queixas compatíveis com insuficiência venosa. Foram considerados obesos aqueles com IMC ≥ 30. Foram avaliados com ecocolor Doppler, para se detectar a presença ou não de refluxo em veias dos membros inferiores, sendo então distribuídos em dois grupos: aqueles com CEAP ≤ 1, além de excluído refluxo, os portadores de flebopatia hipotônica, e outros com CEAP ≥ 2 e com refluxo. Resultados: A amostra foi composta por 89,7% de mulheres e 10,3% de homens, com faixa etária média de 44,9 anos. A flebopatia hipotônica foi mais comum em mulheres (p-valor = 0,0001). Naquelas obesas, houve mais lesão troncular como etiologia dos sintomas venosos do que nas não obesas (p-valor = 0,0017). Dentre os homens, a presença de obesidade não influenciou na etiologia dos sintomas (p-valor = 0,5991). Nos grupos etários de idade mais avançada, a presença de sintomatologia teve como origem etiológica a lesão venosa troncular com mais frequência do que nas faixas etárias mais jovens (p-valor <0,0001). Conclusão: A flebopatia hipotônica se mostrou muito prevalente, principalmente em mulheres jovens não obesas...

Enoftalmos unilateral por várice orbitaria / Enophthalmos secondary to an orbital varix

El enoftalmos es un motivo de consulta poco frecuente en la práctica médica. La mayor parte de los casos se debe a un aumento de la cavidad ósea orbitaria de origen traumático. Presentamos el caso de una mujer de 63 años que consultó por enoftalmos progresivo de su ojo izquierdo, de doce años de evolución. El examen oftalmológico reveló la presencia de un marcado enoftalmos del lado izquierdo, que mejoraba notablemente con maniobras de Valsalva. Una tomografía computarizada y una resonancia magnética de la órbita permitieron diagnosticar una várice orbitaria no complicada. Las várices orbitarias son infrecuentes y por lo general se manifiestan por episodios de exoftalmos intermitente. Sin embargo, en raras ocasiones, la distensión y colapso repetidos pueden llevar a un enoftalmos progresivo por atrofia de la grasa orbitaria.

The enophthalmos is a rare cause of consultation in medical practice. The majority of cases are due to orbital space enlargement of traumatic origin.We report the case of a 63 year old patient with progressive enophthalmos of the left eye, with twelve years of evolution. Ophthalmologic examination revealed the presence of a marked enophthalmos on the left side, which improved significantly with Valsalva maneuvers. A CT scan and an MRI of the orbit allowed diagnosing uncomplicated orbital varices. Orbital varices are rare and usually manifest by episodes of intermittent exophthalmos. However, on rare occasions, repeated distension and collapse can lead to progressive enophthalmos by orbital fat atrophy.

Recurrent and Troublesome Variceal Bleeding from Parastomal Caput Medusae / 대한소화기학회지

Variceal bleeding is common in chronic liver disease and is a frequent cause of acute upper gastrointestinal bleeding. The most common site of varices is the lower oesophagus but they may occur at any location where there are portosystemic anastomoses and collateral vascular formation. Location of ectopic varices at the site of enterocutaneous stomas is rare. We report on three cases of recurrent and severe bleeding from parastomal varices, requiring hospital admission. The patients had chronic liver disease but of different aetiological factors. Variceal formation results from portal hypertension due to chronic liver disease. There are various treatment options for parastomal variceal bleeding, including local, medical, and surgical interventions. Management of parastomal variceal bleeding presents a recurring and difficult problem. Bleeding may be considerable and sometimes life threatening. This diagnosis must be considered in patients with chronic liver disease presenting with stomal bleeding, even where the variceal formation may not be readily visible.

Sclerotherapy in the management of varicose veins and its dermatological complications.

Background: Varicose veins and its dermatological complications like stasis dermatitis, ulcers, spontaneous bleeding are commonly seen in the dermatology clinics. Surgery has been the most often used treatment for varicose veins. Sclerotherapy refers to introduction of sclerosing solution into the varicose veins, which causes endothelial damage and subsequent fibrosis. Sclerotherapy is being practised extensively by dermatosurgeons in the west. However, there are no Indian studies which specifically evaluate the role of sclerotherapy in the management of varicose veins and its skin complications. Hence, this study aims to evaluate the efficacy of sclerotherapy in managing varicose veins and its complications. Aims: To study the safety and efficacy of sclerotherapy in the treatment of varicose veins and its dermatological complications. Methods: This is a prospective study involving 50 patients with varicose veins and its dermatological complications attending the dermatology out-patient department. The study was conducted over a period of 18 months. After thorough clinical, laboratory, and radiological evaluation, the patients were treated with sclerotherapy using Sodium Tetradecyl Sulphate of various concentrations depending on the vessel size. The patients were then followed up to look for disappearance of veins, healing of ulcers and eczema, and any complications.Results: Patients showed a good response to treatment with sclerotherapy. 70-80% of patients showed symptomatic improvement along with disappearance of veins and healing of eczema and ulcers. Most of the complications were minor, which resolved over a period of few weeks. Conclusion : Sclerotherapy is a simple, safe and effective procedure for the treatment of varicose veins and its dermatological complications. The procedure is particularly effective for smaller, early varicosities and also for residual veins after surgery. Hence we recommend more and more of our fellow dermatologists to take up this procedure, which can be an efficient tool to manage patients with varicose veins and its related complications.

Balloon-Occluded Percutaneous Transhepatic Obliteration of Isolated Vesical Varices Causing Gross Hematuria

Gross hematuria secondary to vesical varices is an unusual presentation. We report such a case recurrent gross hematuria in a male patient who had a history of bladder substitution with ileal segments that had been treated by balloon-occluded percutaneous transhepatic obliteration of vesical varices.

Pulmonary varices - rare cause of haemoptysis

Haemoptysis has a long list of causes, but pulmonary varices are amongst the rare causes. Pulmonary varices are rare abnormalities of pulmonary veins that may exist either as an isolated malformation or in association with pulmonary venous hypertension. This case report describes pulmonary varices as a cause of hemoptysis in an adolescent boy, which was diagnosed on multislice CT and confirmed on angiography

Ruptured duodenal varices arising from the main portal vein successfully treated with endoscopic injection sclerotherapy: a case report / 대한간학회지

Duodenal varices result from retroperitoneal portosystemic shunts that usually come from the pancreaticoduodenal vein and drain into the inferior vena cava. Because they are a rare but fatal cause of gastrointestinal bleeding, a prompt hemostatic intervention is mandatory. A 62-year-old man who had a history of excessive alcohol consumption presented with massive hematemesis and melena. Emergent endoscopy revealed ruptured varices with an adhering whitish fibrin clot on the postbulbar portion of the duodenum. Abdominal computed tomography demonstrated a cirrhotic liver with venous collaterals around the duodenum and extravasated contrast in the second and third portions. The collaterals originated from the main portal vein and drained via the right renal vein into the inferior vena cava. Endoscopic injection sclerotherapy with cyanoacrylate was successful in achieving hemostasis, and resulted in the near eradication of duodenal varices at a 6-month follow-up.

A diferença na qualidade de vida de pacientes com doença venosa crônica leve e grave / Differences in the quality of life of patients with mild and severe chronic venous disease

CONTEXTO: A doença venosa crônica atinge os indivíduos em sua fase mais produtiva da vida, acarretando dor, perda de mobilidade e afastamento de atividades, podendo interferir diretamente na qualidade de vida. Seus sintomas clínicos decorrem de um estado de hipertensão venosa, causada por refluxo e/ou obstrução venosa. OBJETIVO: Determinar a diferença na qualidade de vida de pacientes com doença venosa crônica leve e grave. MÉTODOS: Foi realizado estudo transversal analítico comparativo na unidade de saúde durante 8 meses. A amostra foi calculada em 88 pacientes e dividida em dois grupos: Grupo A (CEAP clínico 1, 2 e 3) e Grupo B (CEAP clínico 4, 5 e 6). Foi usado o questionário genérico Medical Outcomes Study - 36-Item Short-Form Health Survey (SF-36). A análise estatística para verificar se havia diferença foi através do teste t de Student, com intervalo de confiança de 95 por cento e p < 0,05. RESULTADOS: Foram analisados 88 indivíduos, sendo 47 no grupo A e 41 no grupo B. Do total, 87,5 por cento (77) eram mulheres. Com relação à idade, 34 por cento (30) tinham entre 30 e 40 anos. As alterações subcutâneas (CEAP clínico 4) foram os sintomas mais presentes, em 28,4 por cento. Com exceção do domínio estado geral da saúde, todos os outros mostraram que o grupo B apresentava escores inferiores quando comparado ao grupo A. CONCLUSÕES: A qualidade de vida dos pacientes com doença venosa crônica leve e grave é diferente, apresentando-se mais afetada de acordo com a gravidade.

BACKGROUND: Chronic venous disease afflicts individuals in their most productive years, resulting in pain and loss of mobility and independence in performing routine daily activities, which may directly interfere with the patient's quality of life. Clinical symptoms result from venous hypertension caused by reflux and/or venous blockage. OBJECTIVE: To determine differences in the quality of life of patients with mild and severe chronic venous disease. METHODS: A cross-sectional comparative study was conducted in a health care facility during an 8-month period. The sample was composed of 88 patients divided into two groups: group A (clinical CEAP class 1, 2 and 3) and group B (clinical CEAP class 4, 5 and 6). The Medical Outcomes Study - 36-Item Short-Form Health Survey (SF-36) questionnaire was used. Statistical analysis was conducted using the Student t test, with a 95 percent confidence interval and a level of significance set at p < 0.05. RESULTS: We analyzed 88 subjects, 47 in group A and 41 in group B. Of the total, 87.5 percent (77) were women and 34 percent (30) were aged 30 to 40 years. Subcutaneous changes (CEAP class 4) were the most common symptoms, observed in 28.4 percent of the individuals. Except for the general health perceptions domain, group B showed lower scores than group A in all other domains. CONCLUSIONS: The quality of life of patients with mild and severe chronic venous disease proved to be different according to disease severity.

Pulsating enophthalmos in association with an orbital varix.

We report a case of pulsating enophthalmos secondary to orbital varix associated with orbital bony defects. A 64-year-old female with pulsating enophthalmos of the right eye was found to have a right orbital mass with bony defects of the orbit. Valsalva maneuver failed to induce proptosis. The diagnosis of orbital varix was confirmed by exploratory orbitotomy. During general anesthesia for orbitotomy, proptosis of the right eye was noted. Ophthalmologists should be aware of the association between orbital varices and cranial bony defects and encephaloceles. Proptosis induced by general anesthesia and positive pressure ventilation suggests an underlying distensible venous anomaly.

Cirurgia de varizes dos membros inferiores em pacientes receptores de transplante hepático: relato de caso / Surgical treatment of varicose veins of the lower limbs in liver transplant recipients: a case report

O transplante hepático vem progressivamente apresentando melhores resultados e maior preocupação com a qualidade de vida dos pacientes. As varizes dos membros inferiores são comuns na população e causam sintomas em boa parte dos casos, comprometendo a qualidade de vida. Em pacientes com boa condição clínica e funcionamento normal do enxerto, o tratamento cirúrgico das varizes de membros inferiores pode ser a opção com resultado mais eficaz e duradouro. Os autores relatam dois casos de pacientes que haviam sido submetidos a transplante hepático e apresentavam varizes sintomáticas de membros inferiores, e foram submetidos a cirurgia de varizes após liberação pela equipe de transplante hepático. As operações ocorreram sem intercorrências, com bom resultado no seguimento. A cirurgia de varizes dos membros inferiores pode ser realizada com segurança em pacientes receptores de transplante hepático, sendo uma opção eficaz e duradoura no tratamento da insuficiência venosa crônica nesses pacientes.

Liver transplantation is having progressively better outcomes, and quality of life is being more often addressed. Varicose veins of the lower limbs are common in the general population and cause symptoms in a significant number of cases, impairing quality of life. For patients in good clinical condition, with adequate graft function, surgical treatment for varicose veins of the lower limbs can be a safe option, with more effective and longer lasting outcomes. The authors report two cases of liver transplant recipients who had symptomatic varicose veins of the lower limbs and were submitted to varicose vein surgery following authorization from the liver transplantation team. Operations were uneventful, with good follow-up results. Surgery for varicose veins of the lower limbs can be safely performed in liver transplant recipients, and it is an effective and long lasting treatment for chronic venous insufficiency in these patients.

Avaliação do refluxo venoso superficial ao mapeamento dúplex em portadores de varizes primárias de membros inferiores: correlação com a gravidade clínica da classificação CEAP / Evaluation of venous reflux by color duplex scanning in patients with varicose veins of the lower limbs: correlation with clinical severity by CEAP classification

Contexto: As alterações de pele manifestadas na insuficiência venosa crônica têm como etiologia mais comum o refluxo venoso. Alguns autores relatam que o refluxo venoso superficial é responsável por 40-60 por cento das úlceras de perna nos portadores de varizes primárias. Objetivo: Correlação do refluxo venoso superficial ao mapeamento dúplex com o quadro clínico (classificação CEAP - clínica, epidemiológica, anatômica e fisiopatológica) nos portadores de varizes primárias de membros inferiores. Método: Estudo transversal e descritivo, desenvolvido em portadores de varizes primárias. As variáveis primárias foram: refluxo venoso e quadro clínico. O quadro clínico foi caracterizado por grupos: A, B e C, representados pelas categorias clínicas da CEAP. Dados complementares foram: tipos de refluxo em veias safenas magnas e parvas, conforme classificação de Engelhorn (2004). Testaram-se as hipóteses de inter-relações entre presença de refluxo e quadro clínico, utilizando-se os testes exato de Fisher e qui-quadrado no nível de 5 por cento de probabilidade. Resultados: Das 242 extremidades inferiores examinadas, 15 foram excluídas, totalizando 227 na amostra final. Noventa e nove (83,9 por cento) pacientes eram do sexo feminino. A média de idade foi de 50 anos, com mediana igual a 49 anos. Noventa e três extremidades (41 por cento) não apresentavam refluxo, e 134 (59 por cento) o apresentavam isolado e/ou associado. O refluxo isolado em veias perfurantes (p = 0,0008) e destas em associação com o refluxo em veias safenas magnas (p < 0,0001) estão significativamente relacionados à gravidade do quadro clínico. Conclusão: Há correlação entre a presença do refluxo venoso superficial ao mapeamento dúplex e a gravidade do quadro clínico nos portadores de varizes primárias de membros inferiores.

Background: Skin changes observed in chronic venous insufficiency have venous reflux as the most common etiology. Some authors have reported that reflux in the superficial venous system accounts for 40-60 percent of leg ulcers in patients with primary varicose veins. Objective: To evaluate the correlation between superficial venous reflux and clinical status (CEAP classification - clinical, etiology, anatomy and pathophysiology) in patients with primary varicose veins of the lower limbs using duplex scanning. Method: A cross-sectional and descriptive study was performed in patients with primary varicose veins. Primary variables were venous reflux and clinical status. Clinical status was characterized by groups A, B, and C, represented by CEAP clinical categories. Types of venous reflux in the great and small saphenous veins were used as complementary data, according to Engelhorn's classification (2004). Hypotheses of interrelationship between incidence and types of reflux were statistically analyzed using Fisher's exact and chi-square tests. Significance was set at 0.05 percent. Results: Of 242 lower limbs, 15 were excluded, so that the final sample was comprised of 227 lower limbs. Ninety-nine (83.9 percent) patients were female. Mean age was 50 years and median was 49 years. Reflux was absent in 93 limbs (41 percent), and 134 (59 percent) showed isolated and/or associated reflux. Isolated reflux in perforating veins (p = 0.0008) or in association with great saphenous vein reflux (p < 0.0001) was significantly related to clinical status severity. Conclusion: Duplex scan showed correlation between presence of superficial venous reflux and clinical status severity in patients with primary varicose veins of the lower limbs.

Estudo da hemodinâmica venosa por meio da pletismografia a ar no pré e pós-operatório de varizes dos membros inferiores / Venous hemodynamic study by air plethysmography in the pre- and postoperative period of lower limb varicose veins

Contexto: O tratamento cirúrgico das varizes primárias dos membros inferiores deve proporcionar alívio da estase venosa, a fim de evitar a evolução da doença venosa para estágios de maior gravidade clínica. Objetivo: Estudar as alterações da hemodinâmica venosa em pacientes portadores de varizes primárias dos membros inferiores no pré e pós-operatório, utilizando a pletismografia a ar. Método: Foram estudados 63 membros inferiores em 39 pacientes (35 mulheres e quatro homens), com média de idade igual a 46,3 anos, operados no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, no período de janeiro de 2001 a dezembro de 2004. Os membros inferiores foram classificados de acordo com a classificação CEAP, em critério clínico = C2 a C6 (C2 = 6, C3 = 32, C4 = 15, C5 = 7 e C6 = 3), critério etiológico = Ep, critério anatômico = As e critério fisiopatológico = Pr. Os pacientes foram avaliados por exame clínico pré e pós-operatório, mapeamento dúplex pré-operatório e pletismografia a ar pré e pós-operatória. Resultados: Houve melhora da hemodinâmica venosa no pós-operatório, demonstrada pela diminuição do índice de enchimento venoso e da fração de volume residual e aumento da fração de ejeção nos membros inferiores submetidos à operação de varizes. Conclusão: A operação venosa superficial aliviou a estase venosa e proporcionou adequado tratamento, com o objetivo de interromper a evolução fisiopatológica da doença venosa crônica, em qualquer nível de gravidade clínica.

Background: Surgical treatment of primary varicose veins of the lower limbs might contribute to venous stasis relief by preventing evolution of the venous disease to worse severity stages. Objective: To study venous hemodynamic changes in patients with primary varicose veins of the lower limbs during the pre- and postoperative period using air plethysmography. Method: Sixty-three lower limbs of 39 patients (35 females and four males, mean age of 46.3 years) were evaluated. They were all operated at Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, between January 2001 and December 2004. Lower limbs were classified according to the CEAP classification: clinical criteria = C2 to C6 (C2 = 6, C3 = 32, C4 = 15, C5 = 7 and C6 = 3), etiologic criteria = Ep, anatomic criteria = As, and pathophysiological criteria = Pr. The patients were submitted to pre- and postoperative clinical examination, preoperative duplex scan and pre- and postoperative air plethysmography. Results: Improvement in venous hemodynamics was observed after surgery, confirmed by reduction in the venous filling index and residual volume fraction and increase in the ejection fraction in the lower limbs submitted to varicose vein surgery. Conclusion: Superficial varicose vein stripping contributed to venous stasis relief and provided appropriate treatment, preventing pathophysiological evolution of chronic venous disease independently of clinical severity.

Utilización de la resonancia magnética con contraste de fase para el diagnóstico del síndrome de congestión pelviana / Using phase contrast MRA for the diagnosis of pelvic congestion syndrome

Introduction: Pelvic congestion syndrome (PCS) is produced by anomalous flow in ovarían veins. Direct venography (DV) is the gold-standard for diagnosis. Phase-Contrast Magnetic Resonance Angiography (PC-MRA) appears as an alternative that would permit a morphological and functional assessment. The purpose of the study was to evaluate the usefulness of flow velocity (measured with PC-MRA) as a diagnostic criterion and also to compare it with the DV technique. Patients and methods: We prospectively included 8 female patients with clinical suspicion of PCS who were referred for undergoing DV over a six-month period. PC-MRA examinations were performed in all of them. Slow anterograde or retrograde flow were the diagnostic criteria. Sensitivity, specificity, PPV, and NPV were also calculated. Results: Data from 16 veins were analized by means of a home-made software written in Matlab. There were 12 abnormal and 4 normal veins according to DV results. All the abnormal veins were correctly identified by MR-PC. Two veins (corresponding to the same patient) were considered as normal in accordance with DV results, whereas the PC-MRA analysis revealed them as abnormal veins. This patient presented with PCS typical symptoms. Sensitivity and specificity values were 100 and 50 percent, respectively, whereas PPV and NPV values were 86 and 100 percent, respectively. Conclusion: PC-MRA is a useful diagnostic tool for patients with clinical suspicion of PCS and could avoid unnecessary invasive procedures.

Introducción: El síndrome de congestión pelviana (SCP) es producido por flujo anómalo en las venas ováricas. La venografía directa (VD) es el estándar de referencia. La resonancia magnética con contraste de fase (MR-CF) permitiría una evaluación morfológica y funcional. El propósito fue evaluar la utilidad de la velocidad de flujo medida con RM-CF como criterio diagnóstico comparado con VD. Pacientes y Métodos: Incluimos prospectivamente 8 pacientes derivadas para VD por sospecha de SCP durante 6 meses; todas fueron sometidas a RM-CF. Los criterios diagnósticos fueron: flujo retrógrado o anterógrado lento. Se calculó sensibilidad, especificidad, VPP y VPN. Resultados: Analizamos los datos de 16 venas, utilizando un software propietario escrito en Matlab. Hubo 12 venas anormales y 4 venas normales en VD. Todas la venas anormales fueron correctamente identificadas por MR-PC. Dos venas (la misma paciente) fueron normales en VD y anormales en MR-PC. Esta paciente tenía clásicos síntomas de SCP La sensibilidad fue de 100 por ciento, especifidad de 50 por ciento, VPP de 86 por ciento y VPN de 100 por ciento Discusión: MR-PC es una herramienta útil en el diagnóstico del SCP y evitaría exámenes invasivos innecesarios.