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Arq. bras. cardiol ; 117(4): 657-663, Oct. 2021. tab, graf
Article in English, Portuguese | LILACS | ID: biblio-1345229


Resumo Fundamento Tendo em vista os casos de lactentes sintomáticos com Tetralogia de Fallot (TF), baixo peso ao nascimento e anatomia complexa, o implante de stent na via de saída do ventrículo direito (VSVD) tem sido indicado alternativamente à cirurgia de Blalock-Taussig (BT). Objetivo Avaliar o implante endovascular de stent na VSVD como abordagem primária no lactente com TF e não candidato à cirurgia de BT, bem como relatar seus resultados a médio prazo e até a retirada do stent na cirurgia corretiva. Métodos Entre outubro de 2015 e abril de 2018, uma série de seis lactentes portadores de TF receberam stents para desobstrução da VSVD. Os parâmetros hemodinâmicos foram comparados em períodos pré e pós-implante. Resultados As medianas de idade e peso no momento do procedimento foram de 146,5 dias e 4,9 kg, respectivamente. O gradiente sistólico máximo diminuiu de 63,5 mmHg para 50,5 mmHg, enquanto o diâmetro dos ramos pulmonares direito e esquerdo aumentou de 3,5 mm para 4,9 mm e 4,3 mm, respectivamente. O índice de Nakata aumentou de 96,5 mm para 108,3 mm; assim como o peso, de 4,9 kg para 5,5 kg. A saturação de oxigênio aumentou de 83,5% para 93%. Houve um caso de migração do stent e dois óbitos, um deles devido à embolização do stent e o outro não teve relação com o procedimento. Conclusões O implante de stent na VSVD como procedimento paliativo na TF se mostra uma alternativa promissora para o tratamento de lactentes com má anatomia e baixo peso ao nascimento.

Abstract Background Endovascular stent placement in the right ventricular outflow tract (RVOT) has been an alternative to Blalock-Taussig (BT) surgery in the treatment of Tetralogy of Fallot (TOF) in symptomatic infants with low birth weight and complex anatomy. Objective To evaluate endovascular stent placement in the RVOT as a primary treatment for infants with TOF who are not candidates for BT surgery, and evaluate medium-term outcomes until the stent is removed during corrective surgery. Methods Six infants with TOF were treated with RVOT stenting from October 2015 to April 2018. Hemodynamic parameters were compared between the pre- and post-stenting periods. Results At the time of stenting, participants had a median age and weight of 146.5 days and 4.9 kg, respectively. Peak systolic gradient decreased from 63.5 mm Hg to 50.5 mm Hg, while the diameter of the left and right pulmonary arteries increased from 3.5 mm to 4.9 mm and 4.3 mm, respectively. The Nakata index increased from 96.5 mm to 108.3 mm; weight increased from 4.9 kg to 5.5 kg; and oxygen saturation, from 83.5% to 93%. There was one case of stent migration and two deaths, one caused by stent embolization and the other unrelated to study procedures. Conclusions RVOT stenting is a promising alternative for the palliative treatment of TOF in infants with low birth weight and complex anatomy.

Humans , Infant , Tetralogy of Fallot/surgery , Blalock-Taussig Procedure , Palliative Care , Pulmonary Artery/surgery , Retrospective Studies , Treatment Outcome
Rev. bras. cir. cardiovasc ; 35(4): 445-451, July-Aug. 2020. tab, graf
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1137300


Abstract Objective: To evaluate surgical management and results of patients with pulmonary atresia and ventricular septal defect with major aortopulmonary collateral arteries (PA/VSD/MAPCAs). Methods: We reviewed a consecutive series of patients with PA/VSD/MAPCAs between January 2012 and October 2018. Study patients were separated into Group A, efficient MAPCAs; Group B, hypoplastic MAPCAs; Group C, severe hypoplastic MAPCAs at all divisions; and Group D, distal stenosis at most MAPCAs divisions. Results: Thirty-six patients were included in the study. Median age at operation time was 5.5 months (2-110 months), median weight was 8 kg (2.5-21 kg), and median number of MAPCAs was three (1-6). In Group A, 14 patients underwent single-stage total correction (TC); in Group B, 18 patients underwent unifocalization and central shunting; and in Group C, four patients had aortopulmonary window creation and collateral ligation. No patient was placed in Group D. Seventy percent of patients (n=25) had the TC operation. Early mortality was not seen in Group A, but the other two groups had a 13.6% mortality rate. At the follow-up, three patients had reintervention, two had new conduit replacement, and one had right ventricular outflow tract reconstruction. Conclusion: Evaluating patients with PA/VSD/MAPCAs in detail and subdividing them is quite useful in determining the appropriate surgical approach. With this strategy, TC can be achieved in most patients. Single-stage TC is better than other surgical methods due to its lower mortality and reintervention rates. Care should be taken in terms of early postoperative intensive care complications and reintervention indications during follow-ups.

Humans , Male , Female , Infant , Child, Preschool , Child , Pulmonary Atresia/surgery , Heart Septal Defects/surgery , Cardiac Surgical Procedures , Pulmonary Artery/surgery , Pulmonary Artery/diagnostic imaging , Retrospective Studies , Collateral Circulation
Rev. bras. cir. cardiovasc ; 35(3): 392-395, May-June 2020. tab, graf
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1137260


Abstract Coronary fistulas are rare anomalies that can affect approximately 1% of the population, presenting few specific symptoms, and are often found occasionally in coronary angiography. Here we describe the case of a 61-year-old patient with complaints of precordialgia and dyspnea since adolescence, with late diagnosis of coronary fistulas with drainage to the pulmonary artery, and with unsuccessful percutaneous treatment. Therefore, she underwent open surgery for the correction of the already known fistulas, in addition to the hemangioma involving such vessels, which made the understanding and resolution of this case more complex.

Humans , Female , Middle Aged , Arterio-Arterial Fistula/surgery , Arterio-Arterial Fistula/diagnostic imaging , Pulmonary Artery/surgery , Pulmonary Artery/diagnostic imaging , Coronary Angiography
Rev. bras. cir. cardiovasc ; 35(3): 402-405, May-June 2020. tab, graf
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1137255


Abstract Type II Aortopulmonary window (APW) accounts for only 10% of total cases of APW, which by itself is a rare congenital anomaly. Various cardiac malformations have been reported to be associated with this rare anomaly. We report one such association of origin of left subclavian artery (LSCA) from left pulmonary artery (LPA) via ductus arteriosus that was surgically repaired.

Humans , Aortopulmonary Septal Defect/surgery , Aortopulmonary Septal Defect/complications , Aortopulmonary Septal Defect/diagnostic imaging , Subclavian Artery/surgery , Subclavian Artery/diagnostic imaging , Aorta, Thoracic/surgery , Aorta, Thoracic/diagnostic imaging , Pulmonary Artery/surgery , Pulmonary Artery/diagnostic imaging , Lung
Rev. bras. cir. cardiovasc ; 33(4): 424-427, July-Aug. 2018. tab, graf
Article in English | LILACS | ID: biblio-958434


Abstract Aortopulmonary septal defect, also known as the aortopulmonary window, is a rare congenital macrovascular malformation. This case involves a 9-year-old boy with aortopulmonary septal defect (type I combined with type IV). Before surgery, milrinone and alprostadil were used to counteract high lung pressure. Surgery was performed under cardiopulmonary bypass, following which the pulmonary pressure decreased. The aorta was cut, and the right pulmonary artery opening was connected with the main pulmonary artery septal defect using polyester patch. An internal tunnel was made, and the deformity correction was completed. The child exhibited normal postoperative recovery with no discomfort. A complex aortopulmonary window is a rare condition that can be treated successfully with appropriate preoperative and surgical management.

Humans , Male , Child , Aortopulmonary Septal Defect/surgery , Aorta/surgery , Aorta/diagnostic imaging , Aortopulmonary Septal Defect/physiopathology , Aortopulmonary Septal Defect/diagnostic imaging , Pulmonary Artery/surgery , Pulmonary Artery/diagnostic imaging , Blood Pressure , Echocardiography , Tomography, X-Ray Computed , Treatment Outcome , Rare Diseases
Rev. bras. cir. cardiovasc ; 32(3): 210-214, May-June 2017. tab, graf
Article in English | LILACS | ID: biblio-897913


Abstract Introduction: Although it only corresponds to 2.5% of congenital heart defects, hypoplastic left heart syndrome (HLHS) is responsible for more than 25% of cardiac deaths in the first week of life. Palliative surgery performed after the second week of life is considered an important risk factor in the treatment of HLHS. Objective: The aim of this study is to describe the initial experience of a medical center in Northeastern Brazil with a modified off-pump hybrid approach for palliation of HLHS. Methods: From November 2012 through November 2015, the medical records of 8 patients with HLHS undergoing hybrid procedure were retrospectively evaluated in a tertiary private hospital in Northeastern Brazil. The modified off-pump hybrid palliation consisted of stenting of the ductus arteriosus guided by fluoroscopy without contrast and banding of the main pulmonary artery branches. Demographic and clinical variables were recorded for descriptive analysis. Results: Eight patients were included in this study, of whom 37.5% were female. The median age and weight at the time of the procedure was 2 days (p25% and p75% = 2 and 4.5 days, respectively) and 3150 g (p25% and p75% = 3077.5 g and 3400 g, respectively), respectively. The median length in intensive care unit stay was 6 days (p25% and p75% = 3.5% and 8 days, respectively). There were no in-hospital deaths. Four patients have undergone to the second stage of the surgical treatment of HLHS. Conclusion: In this series, the initial experience with the modified off-pump hybrid procedure showed to be safe, allowing a low early mortality rate among children presenting HLHS.

Humans , Male , Female , Infant, Newborn , Cardiac Catheterization/methods , Stents , Hypoplastic Left Heart Syndrome/surgery , Norwood Procedures/methods , Palliative Care/methods , Polytetrafluoroethylene , Pulmonary Artery/surgery , Time Factors , Brazil , Blood Vessel Prosthesis , Cardiac Catheterization/mortality , Intensive Care Units, Neonatal , Reproducibility of Results , Retrospective Studies , Risk Factors , Treatment Outcome , Hypoplastic Left Heart Syndrome/mortality , Ductus Arteriosus/surgery , Norwood Procedures/mortality , Length of Stay , Medical Illustration
Rev. bras. anestesiol ; 67(1): 95-99, Jan.-Feb. 2017. graf
Article in English | LILACS | ID: biblio-843358


Abstract Background and objectives: The aneurysm in the pulmonary trunk is a rare disease. Because of its location, a rupture can lead to right ventricular failure and sudden death. Aneurysmorraphy is the most widely used surgical treatment in these cases. The aim of this study is to report a successful balanced general anesthesia for aneurysmorraphy of pulmonary trunk. Case report: Male patient, 28 years, asymptomatic, diagnosed with an aneurysm in the pulmonary trunk. According to the location of the aneurysm and the consequent failure of the pulmonary valve, an aneurysmorraphy was indicated, with implantation of vascular-valvular prosthesis (valved tube). We opted for a balanced general anesthesia, seeking to prevent an increase in systemic and pulmonary vascular resistances, thus avoiding to cause stress on the wall of the aneurysmal vessel. Conclusions: A balanced general anesthesia, in combination with adequate ventilation to prevent elevation in pulmonary vascular pressure, was appropriate for surgical repair of an aneurysm in the pulmonary trunk.

Resumo Justificativa e objetivos: O aneurisma de tronco de artéria pulmonar é uma doença rara. Por sua localização, uma ruptura pode conduzir à falência do ventrículo direito e à morte súbita. A aneurismorrafia é o tratamento cirúrgico mais usado nesses casos. O objetivo foi relatar uma anestesia geral balanceada para aneurismorrafia de tronco de artéria pulmonar feita com sucesso. Relato do caso: Paciente do sexo masculino, 28 anos, assintomático, diagnosticado com aneurisma de tronco de artéria pulmonar. De acordo com a localização do aneurisma e a consequente insuficiência da válvula pulmonar, foi indicada a aneurismorrafia com implante de prótese vascular e valvular (tubo valvado). Optou-se pela anestesia geral balanceada, para impedir um aumento nas resistências vasculares sistêmicas e pulmonar e evitar-se, dessa maneira, um estresse sobre a parede do vaso aneurismático. Conclusões: A anestesia geral balanceada, em associação com uma ventilação adequada para evitar elevação na pressão vascular pulmonar, foi apropriada para correção cirúrgica de um aneurisma em tronco pulmonar.

Humans , Male , Adult , Pulmonary Artery/surgery , Pulmonary Valve/surgery , Aneurysm/surgery , Pulmonary Artery/drug effects , Heart Valve Prosthesis , Radiography , Heart Valve Prosthesis Implantation/methods , Aneurysm/diagnostic imaging
Arq. bras. cardiol ; 107(6): 600-604, Dec. 2016. graf
Article in English | LILACS | ID: biblio-838664


Abstract Extracorporeal membrane oxygenation (ECMO) is a well-established tool of cardiopulmonary circulatory support for cardiopulmonary failure in children and adults. It has been used as a supportive strategy during interventional procedures in neonates with congenital heart disease. Herein, we describe a neonate with hypoplastic left heart syndrome who underwent stenting of the Sano shunt and left pulmonary artery after Norwood Sano operation using intra-procedural ECMO support. The use of ECMO as a bridge to recovery might be a feasible and reasonably safe adjunctive approach in the treatment of complications in selective case of neonates having undergone the Norwood Sano procedure.

Resumo A oxigenação por membrana extracorpórea (ECMO) é uma ferramenta bem estabelecida de suporte circulatório em casos de insuficiência em crianças e adultos. A ECMO tem sido utilizada como uma estratégia de suporte durante procedimentos interventistas em recém-nascidos com doença cardíaca congênita. Descrevemos o caso de um recém-nascido com síndrome do coração esquerdo hipoplásico que foi submetido à colocação de um stent em shunt de Sano e artéria pulmonar esquerda após procedimento de Norwood-Sano utilizando-se a ECMO como suporte. O uso da ECMO pode ser uma estratégia adjunta viável e segura no tratamento de complicações em casos eletivos de recém-nascidos submetidos à operação de Norwood-Sano.

Humans , Male , Arteriovenous Shunt, Surgical/methods , Extracorporeal Membrane Oxygenation/methods , Stents , Hypoplastic Left Heart Syndrome/surgery , Norwood Procedures/methods , Pulmonary Artery/surgery , Angiography/methods , Reproducibility of Results , Treatment Outcome , Prosthesis Implantation/methods
Rev. bras. cardiol. invasiva ; 23(2): 148-151, abr.-jun. 2016. ilus
Article in Portuguese | LILACS | ID: lil-787000


Relatamos o caso de um paciente portador de hipertensão pulmonar de origem esquistossomótica, que procurou pronto atendimento por apresentar quadro de dor torácica em repouso. A apresentação clínica e os demais dados referentes ao caso levantaram a suspeita de insuficiência coronariana aguda, e foi diagnosticada uma obstrução grave do tronco da coronária esquerda. O relato do caso teve por objetivo destacar a necessidade do diagnóstico diferencial da queixa de dor torácica nestes pacientes e ressaltar a opção da intervenção coronariana percutânea como tratamento eficaz e seguro neste cenário.

This report describes a patient with pulmonary hypertension secondary to schistosomiasis, who sought emergency care due to chest pain at rest. The clinical presentation and other information related to the case raised the suspicion of acute coronary failure, and a severe obstruction was identified in the left main coronary artery. The case report aimed to highlight the need for a differential diagnosis of chest pain complaints in these patients, and emphasizes the choice of percutaneous coronary intervention as an effective and safe treatment in this scenario.

Humans , Male , Aged , Angina Pectoris/complications , Pulmonary Artery/surgery , Schistosomiasis/complications , Schistosomiasis/therapy , Angiography/methods , Bundle-Branch Block/complications , Chest Pain/complications , Echocardiography/methods , Hypertension, Pulmonary , Stents , Ultrasonography/methods
Rev. Soc. Cardiol. Estado de Säo Paulo ; 26(1): 14-20, jan.-mar.2016. tab
Article in Portuguese | LILACS | ID: lil-789771


O choque cardiogênico é uma síndrome clínica caracterizada por hipoperfusão tecidual secundária à disfunção cardíaca, na ausência de hipovolemia. A etiologia principal é o infarto agudo do miocárdio com falência de ventrículo esquerdo, embora existam outras causas relevantes, como complicações mecânicas do infarto, miocardites, evolução de cardiomiopatias, valvopatias agudas não isquêmicas e cardiomiopatia induzida pelo estresse, por exemplo. Apesar dos avanços terapêuticos, persiste como uma afecção de elevada mortalidade e sua incidência não se modificou significativamente nas últimas décadas. A instalação do choque em pacientes com síndromes coronarianasagudas ocorre mais frequentemente após a internação hospitalar, ressaltandoa importância da identificação de preditores e da monitorização de sinais precoces de hipoperfusão tecidual para pronta intervenção. O diagnóstico é essencialmente clínico e alguns exames subsidiários, como eletrocardiograma, marcadores de necrose miocárdica,ecocardiograma e cineangiocoronariografia, que são importantes para a definição da etiologia, estratificação da gravidade e do prognóstico. O manejo adequado dos pacientes requer avaliação dos parâmetros de macro e micro-hemodinâmica. Os principais objetivos terapêuticos incluem a restauração precoce da perfusão tecidual sistêmica ea recuperação da função ventricular. O tratamento inclui medidas gerais para pacientes com choque como ajuste de volemia e adequação da perfusão tecidual com uso de inotrópicos, vasopressores e dispositivos de assistência ventricular, além de medidasespecíficas, direcionadas para a etiologia do choque, como a revascularização precoce nas síndromes coronarianas agudas...

Cardiogenic shock is a clinical syndrome characterized by tissue hypoperfusionsecondary to cardiac dysfunction, in the absence of hypovolemia. Left ventricular failure complicating acute myocardial infarction is the main cause, although other relevant causes include mechanical complications of infarction, myocarditis, progression of cardiomyopathies, acute non-ischemic valvular heart disease, and stress-induced cardiomyopathies, for example. Despite therapeutic advances, it persists as a condition of high mortality, and its incidence has not changed significantly in the last decades.The onset of cardiogenic shock in patients with acute coronary syndromes frequently occurs after hospital admission, reinforcing the importance of identifying predictors and monitoring early signs of tissue hypoperfusion for prompt intervention. The diagnosisis essentially clinical plus some additional tests such as electrocardiogram, myocardial necrosis markers, echocardiogram, and coronary angiography, which are important fordefining the etiology, stratification of severity and prognosis. Proper management of patients requires assessment of macro- and micro-hemodynamic parameters. The maintherapeutic goals include early restoration of tissue perfusion and recovery of ventricular function. Treatment includes general medical care for patients with shock as optimizingvolemia and adjusting of tissue perfusion with inotropic agents, vasopressors and ventricular assist devices, as well as specific interventions focused on the shock etiology, like early revascularization in acute coronary syndromes...

Humans , Shock, Cardiogenic/complications , Shock, Cardiogenic/diagnosis , Myocardial Infarction/etiology , Myocardial Reperfusion/methods , Acute Coronary Syndrome/etiology , Angioplasty/methods , Pulmonary Artery/surgery , Catheters , Dobutamine/administration & dosage , Echocardiography, Doppler/methods , Risk Factors , Prognosis , Thrombolytic Therapy/methods , Heart Ventricles
Rev. bras. cir. cardiovasc ; 30(4): 497-500, July-Aug. 2015. tab, graf
Article in English | LILACS | ID: lil-763165


AbstractThe Glenn operation involving anastomosis of the superior vena cava to the pulmonary artery has been performed for palliative operations of many cyanotic congenital heart diseases in addition to the single ventricle since the 1960s. The classic procedure is done via median sternotomy and cardiopulmonary bypass. The benefits of this procedure without the use of cardiopulmonary bypass remain mixed within reported series. Cases using this approach and off-pump technique together in Latin-America have not yet been reported in the scientific literature.

ResumoA operação de Glenn envolvendo anastomose da veia cava superior à artéria pulmonar foi realizada como procedimento paliativo de muitas doenças cardíacas congênitas cianóticas, além do ventrículo único desde os anos 1960. O procedimento clássico é feito por esternotomia mediana e circulação extracorpórea. Os benefícios deste procedimento sem o uso de circulação extracorpórea permanecem incertos dentro da série relatada. Casos utilizando conjuntamente esta abordagem e a técnica sem circulação extracorpórea na América Latina ainda não foram relatados na literatura científica.

Humans , Infant , Male , Fontan Procedure/methods , Pulmonary Artery/surgery , Thoracotomy/methods , Vena Cava, Superior/surgery , Anastomosis, Surgical/methods , Extracorporeal Circulation , Latin America , Medical Illustration , Photography , Pulmonary Atresia/surgery
Rev. bras. cir. plást ; 30(2): 242-249, 2015. tab
Article in English, Portuguese | LILACS | ID: biblio-1015


Introdução: A embolia pulmonar é a causa de morte mais previsível em pacientes hospitalizados, sendo isso ainda mais prevalente em pacientes cirúrgicos. 200.000 novos casos ocorrem anualmente, com início súbito e geralmente levando à morte nas primeiras 2 horas. Prevenir é, portanto, mais efetivo que tratar a doença estabelecida. Esse estudo objetiva demonstrar a importância e segurança do protocolo de prevenção do tromboembolismo venoso. Métodos: Conduzimos um estudo retrospectivo no período de maio de 2009 a maio de 2011, quando 2759 pacientes foram submetidos à cirurgia plástica no Instituto Ivo Pitanguy. Todos os pacientes foram submetidos ao protocolo de prevenção e avaliados quanto aos fatores de risco para tromboembolismo venoso. A soma desses fatores gerou um escore que determinou a conduta profilática a ser adotada. Resultados: Houve três casos de tromboembolismo venoso (0,1%), sendo 1 de TEP e 2 de TVP. A quimioprofilaxia com enoxaparina administrada aos 3 pacientes de acordo com o protocolo de prevenção. Nossas taxas permaneceram abaixo das encontradas na literatura, com diferença estatisticamente significativa nos numero total de casos (p < 0,0001). Houve 34 casos de hematoma (1,2%), sendo 55,9% em pacientes submetidos à quimioprofilaxia e 44,1% em pacientes que usaram apenas o dispositivo de compressão pneumática intermitente apenas. As taxas totais de hematoma também permaneceram abaixo das encontradas na literatura, também com diferença estatisticamente significativa (p < 0,001). Conclusão: O protocolo de prevenção do tromboembolismo venoso do Instituto Ivo Pitanguy se provou seguro e importante na prevenção dos casos de TEV, com taxas de hematoma abaixo do descrito na literatura.

Introduction: Pulmonary embolism is the most predictable cause of death in hospitalized patients, even more in surgical patients. 200.000 new cases occur annually, with sudden onset and generally leading to death in the first 2 hours. Preventing is most effective than treating stablished disease. This study aims to show the importance and safety of the venous thromboembolism prevention protocol. Methods: We conducted a retrospective study in the period between May 2009 and May 2011 at The Ivo Pitanguy Institute, where 2759 patients underwent plastic surgery (aesthetic and reconstructive). All patients were assessed for predisposing and exposing risk factors for venous thromboembolism and the sum of those factors generated a score determining the prophylactic procedure to be adopted according to the protocol. Results: There were three cases of venous thromboembolism (0.1%): one case of pulmonary embolism and two cases of deep venous thrombosis. Chemoprophylaxis with heparin was administered in the three patients according to the venous thromboembolism prevention protocol. Our rates remained below those found in the literature, with a statistically significant difference in total cases (p < 0.0001). There were 34 cases of hematoma (1.2%): 55.9% in patients submitted to pharmacological prophylaxis with heparin and 44,1% in patients who used sequential compression devices only. The total rates of hematoma also remained below those found in the literature with a statistically significant difference (p < 0,001). Conclusion: The venous thromboembolism prevention protocol of the Ivo Pitanguy Institute proved to be important and safe, preventing the occurrence of venous thromboembolism cases with low rates of hematoma.

Humans , Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , History, 21st Century , Pulmonary Artery , Heparin , Retrospective Studies , Risk Factors , Enoxaparin , Chemoprevention , Protocols , Evaluation Study , Pulmonary Artery/surgery , Pulmonary Artery/pathology , Pulmonary Embolism , Pulmonary Embolism/surgery , Pulmonary Embolism/complications , Pulmonary Embolism/mortality , Pulmonary Embolism/pathology , Pulmonary Embolism/prevention & control , Pulmonary Embolism/drug therapy , Surgery, Plastic , Surgery, Plastic/methods , Heparin/adverse effects , Heparin/therapeutic use , Heparin/pharmacology , Enoxaparin/therapeutic use , Enoxaparin/pharmacology , Chemoprevention/methods , Protocols/methods , Protocols/prevention & control