Prognostic factors for femoropopliteal vascular injuries: surgical decisions matter.

Background: Lower limbs are frequently involved in vascular trauma, but it is still not clear which factors lead to unfavorable clinical outcomes. Objectives: To determine the clinical profile of patients with femoropopliteal injuries, the trauma mechanisms, and treatment and identify which factors led to unfavorable outcomes. Methods: A retrospective study based on the medical records of patients treated from 2017 to 2021. The following data were assessed: sex, age, distance to reach the hospital, trauma mechanism, hypovolemic shock, additional injuries, treatment of vascular injuries, whether fasciotomy was needed, inappropriate intraoperative decisions, and injury severity score. Need for surgical reintervention, amputation, and death were defined as unfavorable outcomes. Univariate, bivariate, and logistic regression analyses were conducted. Results: The sample comprised 94 patients; 83% were men; mean age was 30.8 years; combined arterial and venous injuries prevailed (57.5%); and superficial femoral vessels were the most affected (61.7%). Penetrating mechanisms prevailed (80.9%). Arterial injuries were most frequently treated with venous graft (59.6%) and venous injuries underwent ligation (81.4%). In 15% of cases, inappropriate surgical decisions were detected; most often use of the ipsilateral great saphenous vein for arterial reconstruction. Unfavorable outcomes occurred in 44.7%: surgical reintervention was necessary in 21.3% and limb amputation in 25.5%, while 9.5% of the patients died. Conclusions: These injuries mainly involved young men, victims of gunshot wounds. Superficial femoral vessels were the most injured; concomitant non-vascular trauma was frequent, mainly fractures. Inappropriate surgical decisions increased the need for reinterventions by 34 times. Need for fasciotomy, presence of fracture/dislocation, blunt trauma mechanism, and popliteal artery injury increased the risk of amputation.

Brazilian guidelines on diagnosis and management of traumatic vascular injuries.

Trauma is a leading cause of death, permanent disability, and health care cost worldwide. The young and economically active are the most affected population. Exsanguination due to noncompressible torso hemorrhage is one of the most frequent causes of early death, posing a significant challenge to trauma and vascular surgeons. The possibility of limb loss due to vascular injuries must also be considered. In recent decades, the approach to vascular injuries has been significantly modified. Angiotomography has become the standard method for diagnosis, endovascular techniques are currently incorporated in treatment, and damage control, such as temporary shunts, is now the preferred approach for the patients sustaining physiological derangement. Despite the importance of this topic, few papers in the Brazilian literature have offered guidelines on vascular trauma. The Brazilian Society of Angiology and Vascular Surgery has developed Projetos Diretrizes (Guideline Projects), which includes this publication on vascular trauma. Since treating trauma patients is a multidisciplinary effort, the Brazilian Trauma Society (SBAIT) was invited to participate in this project. Members of both societies reviewed the literature on vascular trauma management and together wrote these guidelines on vascular injuries of neck, thorax, abdomen, and extremities.

Influence of sex and age on inferior vena cava diameter and implications for the implantation of vena cava filters.

Background: Measuring the venous diameter and choosing a compatible vena cava filter are essential to reduce the risk of complications resulting from implantation of these devices. However, there is little information on how the diameter of the inferior vena cava varies with sex and age. Objectives: To determine the influence of patients' gender and age on their inferior vena cava diameter and the suitability of the different models of available filters. Methods: Retrospective analytical study based on computed tomography images. The diameter of the inferior vena cava was measured at 3 points: above the confluence of the common iliac veins, below the renal veins, and midway between these two points (cranial point, caudal point, and midpoint) using Arya® and Carestream PACS® software. The results were classified by sex and age groups. Results: CT scans of 417 patients were analyzed: 245 women and 172 men. The diameters at the midpoint and caudal point were, respectively, 19.1 mm and 20.6 mm in women from 81 to 92 years old and were statistically smaller (p< 0.05) when compared to women aged 19 to 40 years (midpoint: 22.7 mm; caudal point: 23 mm). Similar results were seen in men. Venous diameters at the cranial and caudal points in patients aged from 51 to 70 years were statistically larger in men (cranial point: 24.4 mm; caudal point:22.3 mm) than in women (cranial point: 22.6 mm; caudal point:20.8 mm) (p< 0.05). Conclusions: A smaller diameter was found for the inferior vena cava in older patients of both sexes and the rate of diameter change was similar among men and women.

Primary infectious aortic aneurysm: a case series and review of the literature.

Infectious aneurysms, formerly known as mycotic aneurysms, are rare, most often involve the aorta in young patients, and have a greater tendency to rupture than aneurysms of other etiologies. The most characteristic shape is saccular and the most common etiologic agents are Staphylococcus sp. and Salmonella sp. There is scant and imprecise information in the literature about correct nomenclature, diagnosis, and treatment. The authors present three cases in which diagnostic and therapeutic procedures were documented. In addition to reporting this case series, the authors also present a review of the subject, outlining pertinent diagnostic and therapeutic strategies.

Comparative angiotomographic study of swine vascular anatomy: contributions to research and training models in vascular and endovascular surgery.

BACKGROUND: Medium and large animal models allow researchers to evaluate the efficacy and safety of cardiovascular procedures in systems that resemble human anatomy and can be used to simulate scenarios for training purposes. Although porcine models have been used extensively, many physiological and anatomical features remain unknown or only superficially described. OBJECTIVES: To describe the normal porcine vascular anatomy on computed tomography scans, compare it to human vascular anatomy, and discuss the application of porcine models for open and endovascular procedures. METHODS: Three male Landrace pigs underwent computed tomography. The vascular anatomy of the neck, thorax, abdomen, and limbs was analyzed and described; relevant similarities and differences between porcine and human vascular anatomies and the implications for vascular procedures in pigs are highlighted. RESULTS: The carotid territory, aortic arch, and terminal aorta branches all show marked differences in pigs compared to their human counterparts. Compressions of both left renal and common iliac veins were detected, analogous to those seen in human Nutcracker and May-Thurner syndromes. Vascular measurements (diameters, lengths, and angles) of several different porcine territories are presented. CONCLUSIONS: The data presented should be useful for planning preclinical trials and basic research and for refining surgical training using porcine models in vascular fields.

Compression of left renal vein and left common iliac vein on CT scans: how often are they detected?

BACKGROUND: The nutcracker and May-Thurner syndromes are rare and, although often underdiagnosed, they can cause limiting symptoms. They are frequently considered only after exclusion of other diagnoses and there is no consensus in the literature on prevalence, incidence, or diagnostic criteria. OBJECTIVES: To estimate the frequency of compression of the left common iliac vein and left renal vein in CT scans of the abdomen and pelvis. METHODS: Descriptive, quantitative, cross-sectional study. The criteria used to define compression of the left renal vein were a hilar/aortomesenteric diameter ratio > 4 and aortomesenteric angle < 39° and the criterion for compression of the left common iliac vein was a diameter < 4mm. RESULTS: CT scans of 95 patients were analyzed; 61% were women and 39% were men. Left renal vein compression was observed in 24.2% of the sample, with a mean age of 48.8 years, occurring in 27.6% of the women and 18.9% of the men (p = 0.3366). Compression of the left common iliac vein was detected in 15.7% of the sample, with a mean age of 45.9 years, occurring in 24.1% of the women and 2.7% of the men (p = 0.0024). Both veins were compressed in 7.4% of the patients. CONCLUSIONS: Left renal vein compression was detected in women and men at similar frequencies, whereas left common iliac vein compression was more frequent in women. Both venous compressions were most frequently found in patients aged 41 to 50 years.

Surgical repair of a traumatic carotid-jugular arteriovenous fistula.

Penetrating neck injuries can be life threatening. In about 25% of cases there are vascular injuries, which can progress to formation of arteriovenous fistulas. The authors present a case of delayed open surgery to repair a carotid-jugular fistula and briefly review the diagnosis and treatment options for this condition.

Age and sex and their influence on the anatomy of the abdominal aorta and its branches.

BACKGROUND: It is not clear how patients' age and sex influence the anatomy of the aorta and its branches. OBJECTIVES: To determine the most frequent anatomical patterns of diameter and angulation of the abdominal aorta and its branches and the influence of patients' sex and age on these patterns. METHODS: CT scans with intravenous contrast from 157 patients were analyzed. Diameter and angulations of the abdominal aorta and its branches were measured in individuals of both sexes, classified into five age groups: 20 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, and 61 to 70 years. Eighteen variables were analyzed: 6 arterial origin angles, 9 arterial diameters, rate of diameter enlargement, and patient's sex and age. RadiAnt 4.2.1 DICOM viewer software was used for measurements. RESULTS: The total of 157 CT scans were from 69 men and 88 women. There were statistical differences (p <0.05) in the following results: angle of origin and diameter of the superior mesenteric artery; renal artery angle and diameter; diameter of the common iliac arteries, and diameter and rate of diameter enlargement of the aorta in several segments, but not the segment immediately proximal to the celiac trunk. CONCLUSIONS: The diameters of several aorta segments and of its branches (except the left renal artery) increase progressively with age in both sexes and are larger and have a higher rate of diameter enlargement in men than in women in the same age ranges. Between sexes, the angle of origin of the superior mesenteric artery was larger in men, except between 20 and 30 years, and the angle of origin of the left renal artery was larger in women between 51 and 60 years old.

Damage control for subclavian artery injury.

Mortality from penetrating traumas involving the subclavian vessels can be as high as 60% in pre-hospital settings. Operating room mortality is in the range of 5-30%. This paper presents a case in which a strategy for damage control was employed for a patient with an injury to the origin of the left subclavian artery, using subclavian ligation, with no need for any other intervention, and maintaining viability of the left upper limb via collateral circulation. The authors also review surgical approaches and treatment strategies with a focus on damage control in subclavian vessel injuries.

Improving a training model for vascular surgical techniques.

We describe a low-cost model for training vascular surgical techniques. The model is constructed from cylindrical latex balloons filled with gelatin and fixed to a board for support. Arterial sutures, end-to-side and end-to-end anastomoses, patch, vascular shunt placement, and thromboembolectomy were simulated.

Partial sternotomy for management of iatrogenic brachiocephalic trunk injury during tracheotomy.

The median thoracotomy is an access incision made longitudinally through the sternum and variants can be subdivided into total vertical and partial upper or partial lower vertical incisions. In surgical practice, using a partial median sternotomy is an alternative option that causes less surgical aggression. The brachiocephalic artery is one of the thoracic vessels most often affected in traumas and it can be accessed via a median sternotomy. This report describes use of an upper partial sternotomy to provide access in a case of traumatic iatrogenic injury of the brachiocephalic trunk.

Surgical repair of pseudoaneurysms and complex arteriovenous fistula between popliteal vessels.

An arteriovenous fistula (AVF) is an abnormal and permanent communication between an artery and a vein caused by penetrating traumas or iatrogenic injuries. A penetrating trauma to the endothelial wall can lead to formation of pseudoaneurysms (PSA) and to formation of an AVF. Here, the authors present the case of a patient with a complex AVF of popliteal vessels, associated with popliteal artery pseudoaneurysm, suggested by clinical features and imaging exams, and treated with conventional surgery due to unavailability of a stent graft with appropriate diameter and because endovascular surgery isn't provided at the service where this patient was operated.

The use of silicone prosthesis for correction of the first intermetacarpal space atrophic deformity-review of the surgical technique

Introdução: A deformidade atrófica do primeiro espaço ineterósseo da mão (intermetacarpiano) pode ocorrer por qualquer causa que afete as inervações ulnar e/ou mediana, tais como: hanseníase, diabetes e traumatismos. Em países nos quais a hanseníase é endêmica esta atrofia pode significar um sinal estigmatizante capaz de provocar severas dificuldades sociais e psicológicas. Objetivo: Fazer uma revisão da técnica cirúrgica utilizada na correção da deformidade atrófica do primeiro espaço intermetacarpiano através do implante de prótese de silicone desenvolvida por GÓES. Método: Os dados contidos neste artigo foram obtidos por meio de registro fotográfico, pesquisa na literatura científica e revisão das notas de GÓES. Os autores descrevem a técnica cirúrgica e abordam suas indicações e complicações. Conclusão: O implante de prótese de silicone para o primeiro espaço intermetacarpiano é um procedimento seguro, prático e eficaz para a correção da deformidade causada pela atrofia, de qualquer etiologia, dos músculos primeiro interósseo e adutor do polegar

Reabilitaçäo funcional através da cirurgia da perda da oponência do paciente hanseniano / The functional rehabilitation by surgery of the lack of oponent movement in the Hansen's disease patient

O movimento de oponência realizado pelo polegar é a funçäo mais importante da mäo, justificando-se dessa maneira a extrema necessidade de correçäo dessa funçäo no paciente hanseniano. Neste trabalho, demonstramos sucintamente um conjunto de dez pacientes submetidos à correçäo cirúrgica pela técnica em "y", tecendo-se importantes comentários acerca do ato cirúrgico e dos resultados obtidos

A reabilitaçäo cirúrgica da garra cubital no hanseniano / Surgical rehabilitation of cutital hand-claw patients with Hansen's disease

A garra cubital provocada pelo mal de Hansen pode ser perfeitamente corrigida pelo tratamento cirúrgico, usando-se técnicas convencionais, com pequenas variaçöes, e com o auxílio fundamental da fisioterapia no pré e pós-operatórios. Milhares de pacientes em todo o Brasil aguardam que os ortopedistas e cirurgiöes de mäo reconheçam e lutem pela importância cirúrgica da mäo hansênica. Apresentamos um conjunto de 21 pacientes submetidos a tratamento cirúrgico pela técnica de Zancolli e de Fowler, com modificaçöes de Brand, com recuperaçäo funcional excelente e retorno às suas atividades profissionais sem restriçöes