Diretrizes da Sociedade Brasileira de Angiologia e de Cirurgia Vascular sobre o pé diabético 2023 / Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot

Resumo O pé diabético corresponde a uma interação entre fatores anatômicos, vasculares e neurológicos que representam um desafio na prática clínica. O objetivo deste trabalho foi compilar as principais evidências científicas com base em uma revisão das principais diretrizes, além de artigos publicados nas plataformas Embase, Lilacs e PubMed. O sistema da Sociedade Européia de Cardiologia foi utilizado para desenvolver classes de recomendação e níveis de evidência. Os temas foram divididos em seis capítulos (Capítulo 1-Prevenção de úlceras nos pés de pessoas com diabetes; Capítulo 2-Alívio da pressão de úlceras nos pés de pessoas com diabetes; Capítulo 3-Classificações das úlceras do pé diabético; Capítulo 4-Pé diabético e a doença arterial periférica; Capítulo 5-Infecção e o pé diabético; Capítulo 6-Neuroartropatia de Charcot). A versão atual das Diretrizes sobre pé diabético apresenta importantes recomendações para prevenção, diagnóstico, tratamento e seguimento dos pacientes com pé diabético, oferecendo um guia objetivo para prática médica.

Abstract The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.

Impact of the period of the day on all-cause mortality and major cardiovascular complications after arterial vascular surgeries.

BACKGROUND: Conflicting results are reported about daytime variation on mortality and cardiac outcomes after non-cardiac surgeries. In this cohort study, we evaluate whether the period of the day in which surgeries are performed may influence all-cause mortality and cardiovascular outcomes in patients undergoing non-cardiac arterial vascular procedures. METHODS: 1,267 patients who underwent non-cardiac arterial vascular surgeries between 2012 and 2018 were prospectively included in our cohort and categorized into two groups: morning (7 a.m. to 12 a.m., 79%) and afternoon/night (12:01 p.m. to 6:59 a.m. in the next day, 21%) surgeries. Primary endpoint was all-cause mortality within 30 days and one year. Secondary endpoints were the incidence of perioperative myocardial injury/infarction (PMI), and the incidence of major adverse cardiac events (MACE, including acute myocardial infarction, acute heart failure, arrhythmias, cardiovascular death) at hospital discharge. RESULTS: After adjusting for confounders in the multivariable Cox proportional regression, all-cause mortality rates at 30 days and one year were higher among those who underwent surgery in the afternoon/night (aHR 1.6 [95%CI 1.1-2.3], P = 0.015 and aHR 1.7 [95%CI 1.3-2.2], P < 0.001, respectively). Afternoon/night patients had higher incidence of PMI (aHR 1.4 [95%CI 1.1-1.7], P < 0.001). There was no significant difference in the incidence of MACE (aHR 1.3 [95%CI 0.9-1.7], P = 0.074). CONCLUSIONS: In patients undergoing arterial vascular surgery, being operated in the afternoon/night was independently associated with increased all-cause mortality rates and incidence of perioperative myocardial injury/infarction.

Hemodynamic depression after carotid surgery: Incidence, risk factors and outcomes

Abstract Introduction: Hemodynamic Depression (HD) characterized by hypotension and bradycardia is a complication of carotid surgery due to direct autonomic stimulation in the carotid sinus. The authors believe the incidence of HD is high and possibly related to major cardiac complications. Methods: Analysis of patient records during admissions for carotid surgery between January 2014 and December 2018 in two hospitals. HD was defined as bradycardia or hypotension in the first 24 postoperative hours. Bradycardia was defined as heart rate < 50bpm; hypotension as systolic blood pressure < 90 mmHg, continuous use of vasopressors, or a drop in SBP > 20% compared to preoperative values. Myocardial infarction, stroke, and cardiovascular death were defined as adverse events. Results: Overall, 237 carotid surgeries (178 endarterectomies, 59 angioplasties) were studied, and the global incidence of HD was 54.4% (hypotension in 50.2%, bradycardia in 11.0%, and hypotension and bradycardia in 6.8%). The independent predictors of HD were asymptomatic carotid stenosis (OR = 1.824; 95% CI 1.014 −3.280; p = 0.045), endovascular surgery (OR = 3.319; 95% CI 1.675−6.576; p = 0.001) and intraoperative hypotension or bradycardia (OR = 2.144; 95% CI 1.222−3.762; p = 0.008). Hypotension requiring continuous vasopressor infusion was the only factor independently associated with adverse cardiovascular events (OR = 5.504; 95% CI 1.729-17.529; p = 0.004). Discussion/conclusion: Incidence of Hemodynamic Depression after carotid surgery is high and independently associated with surgical technique, symptomatic repercussion of the carotid stenosis, and intraoperative hypotension or bradycardia. Hypotension requiring the continuous infusion of vasopressors was independently associated with the occurrence of MACE.

Experimental implantation of an arterial substitute made of silicone reinforced with polyester fabric in rabbits

OBJECTIVES: The aim of this study was to analyze silicone tubes with an internal diameter of 4 mm as a possible material for vascular prostheses. METHODS: Grafts were implanted into the infrarenal aortas of 33 rabbits. Fluoroscopic examinations were performed within 150 days after surgical implantation. Sample grafts were analyzed via electron microscopy to evaluate the eventual endothelialization of the prostheses. RESULTS: The patency rates of the prostheses were 87% (±6.7%) after 30 days, 73% (±9.3%) after 60 days and 48% (±12%) after 120 days. The material presented characteristics that support surgical implantation: good tolerance promoted by polyester tear reinforcement, ease of postoperative removal and a lack of pseudoaneurysms. However, intimal hyperplasia was a limiting factor for the patency rate. CONCLUSIONS: We concluded that polydimethylsiloxane has limited potential as an alternative material for small vascular prostheses.

Experimental implantation of an arterial substitute made of silicone reinforced with polyester fabric in rabbits.

OBJECTIVES: The aim of this study was to analyze silicone tubes with an internal diameter of 4 mm as a possible material for vascular prostheses. METHODS: Grafts were implanted into the infrarenal aortas of 33 rabbits. Fluoroscopic examinations were performed within 150 days after surgical implantation. Sample grafts were analyzed via electron microscopy to evaluate the eventual endothelialization of the prostheses. RESULTS: The patency rates of the prostheses were 87% (±6.7%) after 30 days, 73% (±9.3%) after 60 days and 48% (±12%) after 120 days. The material presented characteristics that support surgical implantation: good tolerance promoted by polyester tear reinforcement, ease of postoperative removal and a lack of pseudoaneurysms. However, intimal hyperplasia was a limiting factor for the patency rate. CONCLUSIONS: We concluded that polydimethylsiloxane has limited potential as an alternative material for small vascular prostheses.

Developing a new endograft for the treatment of juxtarenal aortic aneurysms: definition and experimentation.

OBJECTIVES: To analyze angiotomographic parameters of juxtarenal aneurysms to assess the applicability of an endograft model to patients and to create in vitro and in vivo models to assess the new endograft. METHODS: A total of 49 patients with juxtarenal aneurysms were submitted to angiotomographic evaluation, and parameters such as the aortic diameter, the length of the neck, and the angulations of the celiac trunk, superior mesenteric artery and renal arteries; the distances between them; and anatomic variations were analyzed. Based on these parameters, an endograft model was developed and tested in a newly created in vitro model of juxtarenal aneurysm. An experimental model of juxtarenal aneurysm was then established in six pigs weighing 50-60 kg to assess the new endograft model. RESULTS: The angiotomographic parameters of juxtarenal aneurysm measured in this study were similar to those reported in the literature and allowed the development of an endograft based on the hourglass concept, which was applicable to 85.8% of the patients. The in vitro model of juxtarenal aneurysm evidenced good radiopacity and functionality and permitted adjustments in the new device and technical improvements in the procedures for treating these aneurysms. In addition, the porcine model of juxtarenal aneurysm was successfully created in all six animals using a bovine pericardial patch, and use of the new endograft in three pilot procedures evidenced its feasibility. CONCLUSIONS: The Hourglass endograft was rendered applicable to treatment of the majority of patients with juxtarenal aneurysms simply by changing its diameter. Moreover, the new in vitro and in vivo models were shown to be effective for assessing both the presented endograft and experiments assessing the endovascular treatment of juxtarenal aneurysms.

Developing a new endograft for the treatment of juxtarenal aortic aneurysms: definition and experimentation

OBJECTIVES: To analyze angiotomographic parameters of juxtarenal aneurysms to assess the applicability of an endograft model to patients and to create in vitro and in vivo models to assess the new endograft. METHODS: A total of 49 patients with juxtarenal aneurysms were submitted to angiotomographic evaluation, and parameters such as the aortic diameter, the length of the neck, and the angulations of the celiac trunk, superior mesenteric artery and renal arteries; the distances between them; and anatomic variations were analyzed. Based on these parameters, an endograft model was developed and tested in a newly created in vitro model of juxtarenal aneurysm. An experimental model of juxtarenal aneurysm was then established in six pigs weighing 50-60 kg to assess the new endograft model. RESULTS: The angiotomographic parameters of juxtarenal aneurysm measured in this study were similar to those reported in the literature and allowed the development of an endograft based on the hourglass concept, which was applicable to 85.8% of the patients. The in vitro model of juxtarenal aneurysm evidenced good radiopacity and functionality and permitted adjustments in the new device and technical improvements in the procedures for treating these aneurysms. In addition, the porcine model of juxtarenal aneurysm was successfully created in all six animals using a bovine pericardial patch, and use of the new endograft in three pilot procedures evidenced its feasibility. CONCLUSIONS: The Hourglass endograft was rendered applicable to treatment of the majority of patients with juxtarenal aneurysms simply by changing its diameter. Moreover, the new in vitro and in vivo models were shown to be effective for assessing both the presented endograft and experiments assessing the endovascular treatment of juxtarenal aneurysms. .

Open and endovascular repair of juxtarenal abdominal aortic aneurysms: a systematic review.

This systematic review focuses on the 30-day mortality associated with open surgery and fenestrated endografts for short-necked (<15 mm) juxtarenal abdominal aortic aneurysms. A search for studies published in English and indexed in the PubMed and Medline electronic databases from 2002 to 2012 was performed, using "juxtarenal abdominal aortic aneurysm" and "treatment" as the main keywords. Among the 110 potentially relevant studies that were initially identified, eight were in accordance with the inclusion criteria in the analysis. Similar outcomes for open and endovascular repair were observed for 30-day mortality. No differences were observed regarding the secondary outcomes (duration of surgery, hospital stay, postoperative renal dysfunction and late mortality), except that the late mortality rate was significantly higher for the patients treated with open repair after a median follow-up of 24 months. Fenestrated endografting is a viable alternative to conventional surgery in juxtarenal abdominal aortic aneurysms with a proximal neck <15 mm.

Coil embolization of an excluded internal iliac artery aneurysm with rapid expansion via gluteal artery approach.

The aim of the paper is to describe open approach of gluteal arteries for coil embolization of internal iliac artery (IIA) aneurysm. We observed enlargement of the IIA to 5.8 cm at the four-year follow-up evaluation of a 78-year-old man who had undergone surgical abdominal aortic aneurysm repair during which the IIA had been ligated at its origin. Following dissection of the gluteal artery with the patient in the prone position, a catheter was placed inside the aneurysmal sac, and coil embolization was possible to exclude the aneurysm. Postoperative angio-computed tomography showed good coil positioning and no demonstrable blood flow or type 2 endoleak.

Late infra-renal aortic graft infection: a fearsome complication.

Since the 1950s, aortic graft infections (AGIs) constitute one of the most feared complications after reconstructive vascular surgery. This complication is not frequent, ranging from 1% to 2% in the recently reported series; however, the high rate of death and morbidity after therapeutic attempts justifies its dreadful fame. The majority of cases occur during the first month after surgery. Staphylococcus aureus is the cause of 70% of the early infection cases. Late infections, on the other hand, are even rarer, showing a strong relationship with low virulence microorganisms, where Staphylococcus epidermidis is the main cause. Gram-negative bacteria are also observed in late infections, mainly when an aortic or graft enteric fistula is present. Treatment modalities are plenty, but still debatable. The authors report a case of a woman who was operated on 6 years ago for a reconstructive aortic aneurysm with the implantation of an infrarenal Dacron graft in the aorto bifemoral position. She looked for medical assistance with a 2-month history of weight loss, abdominal/back pain, and fever. Her clinical status rapidly deteriorated. A computed tomography of the abdomen disclosed the diagnosis of an AGI. The patient was promptly treated with antibiotics. Surgery was undertaken to explant the infected graft and another graft was placed into the axillobifemoral position. Culture from the infections site was negative. After surgery the patient quickly developed refractory septic shock and died immediately post-operatively.

Autotransplante de rim em 12 casos de lesao da arteria renal / Kidney auto transplantation in 12 cases of renal artery lesion

O objetivo deste trabalho e analisar os resultados em 12 autotransplantes renais, cuja indicaçao cirurgica foi anomalia da arteria renal. O diagnostico foi arterite primaria da aorta em sete casos, displasia fibromuscular em tres e aterosclerose em dois casos. Os pacientes apresentavam hipertensao arterial incontrolavel. O autotransplante foi indicado por razoes bem definidas: fibrose periaortica, reoperaçoes, arterias renais multiplas, lesoes de ramos ou pacientes pediatricos. Em seis casos foi feito o autotransplante convencional, enquanto nos seis restantes empregou-se reconstruçao microcirurgica sob hipotermia prolongada. Nao houve obitos nem nefrectomia secundaria. Em dez casos a reconstruçao arterial foi bem-sucedida, em um foi incompleta e em 1 houve trombose. O autotransplante renal e tecnica alternativa muito util quando os procedimentos habituais nao podem ser empregados com segurança

Reabilitaçäo em doentes amputados por doença arterial periférica

Cinquenta e um pacientes com amputaçöes de membro inferior decorrentes de doença arterial periférica foram avaliados quanto a condiçöes e tempo de reabilitaçäo e acompanhados no seguimento tardio por um período médio de 24 meses. Trinta e três pacientes (64%) eram diabéticos. Sucesso imediato de reabilitaçäo foi considerado como a recuperaçäo da marcha bi-pedal com prótese. Quarenta e cinco pacientes (88%) atingiram esta condiçäo. O tempo médio de reabilitaçäo para amputados ao nível da perna foi de três meses e para amputados ao nível da coxa de cinco meses. No seguimento tardio a avaliaçäo foi feita quanto `a persistência no uso da prótese e grau de independência de vida. A mortalidade foi estudada pelo método atuarial. Todos os pacientes amputados na perna (100%) usavam a prótese para locomoçäo e tinham vida independente no último seguimento, enquanto 75% dos amputados em coxa estavam em uso da prótese e apenas 25% tinham vida totalmente independente. A mortalidade estudada pelo método atuarial foi analisada para pacientes diabéticos e näo diabéticos. Todas as mortes exceto uma ocorreram nos diabéticos, resultando neste grupo sobrevida cumulativa de 31% em 4 anos