Diretrizes da Sociedade Brasileira de Angiologia e Cirurgia Vascular para o tratamento da doença cerebrovascular extracraniana / Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease

Resumo A doença cerebrovascular extracraniana tem sido intensamente investigada em todo o mundo, sendo tema de suma importância para os cirurgiões vasculares. A presente Diretriz foi elaborada pela Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV) em sucessão à Diretriz de 2015. As doenças de etiologia não ateroscleróticas não foram incluídas nesse documento. O objetivo desta Diretriz é congregar as evidências mais robustas nessa área para auxiliar os especialistas no processo decisório do tratamento. Foi utilizada a metodologia AGREE II e o sistema da Sociedade Europeia de Cardiologia para as recomendações e níveis de evidências. As recomendações foram graduadas de I a III, e os níveis de evidência classificados em A, B e C. A presente Diretriz foi dividida em 11 capítulos, que tratam dos vários aspectos da doença cerebrovascular extracraniana: diagnóstico, tratamentos e complicações, de forma atualizada e com as recomendações propostas pela SBACV.

Abstract Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

WSES position paper on vascular emergency surgery.

Trauma, both blunt and penetrating, is extremely common worldwide, as trauma to major vessels. The management of these patients requires specialized surgical skills and techniques of the trauma surgeon. Furthermore few other surgical emergencies require immediate diagnosis and treatment like a ruptured abdominal aortic aneurysm (rAAA). Mortality of patients with a rAAA reaches 85 %, with more than half dying before reaching the hospital. These are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. It is the purpose of this position paper to discuss neck, chest, extremities and abdominal trauma, bringing to light recent evidence based data as well as expert opinions; besides, in this paper we present a review of the recent literature on rAAA and we discuss the rationale for transfer to referral center, the role of preoperative imaging and the pros and cons of Endoluminal repair of rAAA (REVAR) versus Open Repair (OR).

Dissecção espontânea da aorta abdominal infrarrenal / Spontaneous dissection of the infrarenal aorta

A rotura da camada íntima que marca o início da dissecção aórtica se origina na maioria dos casos na aorta torácica, sendo rara a dissecção espontânea da aorta abdominal infra-renal. As três principais causas são: iatrogênica, traumática ou espontânea. A dor abdominal e a isquemia de membros são os sintomas mais comuns e um número significativo de pacientes e´ assintomatico. O diagnóstico tem sido feito através de métodos de imagem como ultrassonografia, tomografia computadorizada, ressonância nuclear magnética e angiografia aliados ao alto índice de suspeição. Relatamos os casos de duas pacientes que apresentaram dissecção de aorta abdominal infrarrenal com quadro de dor abdominal súbita, sem sinais de irritação peritoneal com pulsos presentes e simétricos ao exame físico que deram entrada no pronto socorro do Hospital e Maternidade Celso Pierro da PUC Campinas e que foram tratadas pela equipe de Cirurgia Vascular. As duas pacientes no momento do exame apresentavam-se hipertensas e ao ultrassom apresentavam alteração da conformidade da aorta abdominal que foram tratada s cirurgicamente. Uma paciente foi tratada cirurgicamente submetida a endarterectomia da placa dissecada da aorta abdominal infrarrenal de 2,2 cm de diâmetro e 2,0 cm de extensão. A outra paciente foi submetida a revascularização da aorta abdominal bi-iliaca com prótese de Dacron 16 × 8 mm por apresentar disseccao da aorta abdominal distal. As duas pacientes apresentaram boa evolução pos-operatoria tendo alta hospitalar em bom estado geral.

The rupture of the intimal layer marks the beginning of the aortic dissection, which usually happens in the thoracic aorta. The spontaneous dissection of the infrarenal aorta is rare. The main causes are: iatrogenic, traumatic and spontaneous. Abdominal pain and limb ischemia are the commonest symptoms, and some patients are asymptomatics. The diagnosis is made by ultrasound, computed tomography, nuclear magnetic resonance and angiography, with a high suspicious index. We describe two cases of spontaneous rupture of the infrarenal aorta that were treated surgically. We report two cases of patients who were admitted to the emergency room of Celso Pierro Hospital with infrarenal abdominal aortic dissection and were treated by the vascular surgery group. They have presented sudden abdominal pain, no signs of peritoneal irritation and pulses were presents and simmetrics in physical examination The two patients during the examination were hypertensive and the ultrasound showed abnormal compliance of the abdominal aorta who were treated surgically. One patient was treated surgically with dissected plaque endarterectomy of infrarenal abdominal aorta of 2.2 cm in diameter and 2.0 cm in length. The other patient underwent revascularization of the abdominal aorta with bi-iliac Dacron graft 16 × 8 mm due to distal abdominal aortic dissection. Both patients had good postoperative evolution and they were discharged in good general condition.

Endovenous laser treatment for varicose veins in patients with active ulcers: measurement of intravenous and perivenous temperatures during the procedure.

BACKGROUND: Conventional saphenous vein stripping is difficult to be indicated for the treatment of varicose veins in patients classified as CEAP C4, C5, or C6. OBJECTIVE: This study was developed to evaluate treatment results for varicose veins with active ulcers using endovenous laser (EVL), compared to a group undergoing clinical treatment, during 1 year. PATIENTS AND METHOD: Fifty-two patients presenting with varicose veins with active ulcers for more than 1 year were divided for treatment into two randomized groups: Group 1, clinical treatment, composed of 25 subjects, was submitted to elastic or inelastic compression therapy; Group 2, EVL treatment, composed of 27 subjects, was submitted to great and or small saphenous vein ablation with a 980-nm diode EVL, plus the clinical treatment. Intravenous and perivenous temperatures were measured continuously during the EVL treatment. All patients were followed for 12 months and studied with ultrasound at the beginning and end of the study. The ulcers' areas were evaluated initially and at every 3 months. RESULTS: In 12 months, 81.5% of the wounds in patients in Group 2 and only 24% in patients in Group 1 had healed. Ulcer recurrence rate was 44.4% in Group 1. The mean wound area in Group 1 decreased from 17.48 to 12.76 cm(2) at the end of the year. In Group 2, the wound area decreased from 22.26 to 2.7 cm(2) (p=.0037). Mean intravenous and perivenous temperatures of 79.3 and 43.0 degrees C were recorded. CONCLUSION: The treatment for varicose veins with EVL is safe in patients with active ulcers. Wounds healed faster than in patients undergoing clinical treatment alone during a 1-year period. There was no ulcer recurrence in patients treated with EVL.

Prevalência de dilatação da aorta abdominal em coronariopatas idosos / Prevalence of abdominal aortic dilatation in patients aged 60 years or older with coronary disease

CONTEXTO: A realização de programas de triagem para o aneurisma da aorta abdominal de forma indiscriminada auxiliará uma pequena porcentagem de indivíduos, mas ao considerarmos grupos com fatores de risco relacionados à dilatação da aorta, aumentando a probabilidade da doença, este permitirá um direcionamento adequado dos recursos e um benefício maior à população. Programas direcionados pelas sociedades médicas, permitindo um diagnóstico precoce das doenças vasculares e conseqüentemente um melhor preparo do doente, promoveriam melhores taxas de sobrevida com menor morbidade. OBJETIVO: Avaliar a prevalência da dilatação da aorta abdominal em uma amostra de pacientes idosos com mais de 60 anos de idade, portadores de coronariopatia aterosclerótica diagnosticada por cineangiocoronariografia. MÉTODOS: Para a seleção dessa amostra, levou-se em consideração o fato de que a avaliação pré-operatória de cirurgia vascular não tenhasido a indicação do cateterismo. Procedeu-se então a avaliação, baseada na anamnese, exame físico e Doppler ultra-som da aorta abdominal. A análise estatística iniciou-se com o teste qui-quadrado, com a posterior análise de regressão logística multivariada e regressão logística univariada, considerando significativo um p < 0,05. RESULTADOS: Dos 180 pacientes, 57 (31,7 por cento) dos casos pertencem ao sexo feminino, e 123 (68,3 por cento) ao masculino. A faixa etária variou entre 60 e 80 anos, com idade média de 66,7 anos. Dos 16 indivíduos portadores de dilatação da aorta abdominal (10 aneurismas e 6 ectasias), apenas um era do sexo feminino. O risco para um indivíduo com 1 lesão aterosclerótica coronariana de apresentar dilatação da aorta abdominal foi de 0,4 por cento no grupo avaliado. Da mesma forma, nos portadores de 2 ou 3 lesões, o risco foi de 1,7 por cento, e naqueles com mais de 3 lesões, de 4,5 por cento. Quando associados ao tabagismo, estes valores alteraram-se respectivamente para 6,9, 11,8 e 27,1 por...

BACKGROUND: Indiscriminate screening programs for abdominal aortic aneurysm will help a small percentage of individuals. However, when considering groups with risk factors associated with aortic dilatation, which increases the probability of the disease, such programs will provide an adequate allocation of resources and a greater benefit to the population. Programs guided by medical societies, providing an early diagnosis of vascular diseases and consequently a better preparation of patients, would result in better survival rates with lower morbidity. OBJECTIVE: To evaluate the prevalence of abdominal aortic dilatation in patients aged 60 years or older with atherosclerotic coronary disease diagnosed by coronary angiography. METHODS: The sample selected for this study considered the fact that preoperative assessment of vascular surgery had not been indication for catheterization. Evaluation was then performed, based on anamnesis, physical examination and ultrasound Doppler of the abdominal aorta. Statistical analysis started with chi-square test, with further multivariate logistic regression analysis and univariate logistic regression, with p < 0.05 considered significant. RESULTS: Of 180 patients, 57 (31.7 percent) were female and 123 (68.3 percent) were male. Age varied from 60 to 80 years, with mean of 66.7 years. Among the 16 individuals with abdominal aortic dilatation (10 aneurysms and six dilatations), only one was female. The risk of an individual with one atherosclerotic coronary lesion presenting abdominal aortic dilatation was 0.4 percent. Similarly, in those with two or three lesions the risk was 1.7, and 4.5 percent in those with more than three lesions. When associated with smoking, these values were 6.9, 11.8 and 27.1 percent, respectively. CONCLUSION: The present study leads to the conclusion that prevalence of abdominal aortic dilatation was 8.9 percent (16 out of 180 patients) in this specific sample. It was more prevalent...

Tratamento de varizes com laser endovenoso: estudo prospectivo com seguimento de 39 meses / Treatment of varicose veins with endovenous laser: a prospective 39-month follow-up study

OBJETIVO: Avaliar os resultados da terapêutica endovenosa com laser no tratamento de varizes primárias. PACIENTES E MÉTODO: No período compreendido entre julho de 2001 e setembro de 2004 (39 meses), 253 pacientes (417 membros) foram tratados ambulatorialmente com laser de diodo de 810 e 980-nm, com energia liberada endovenosamente através de fibra óptica introduzida por punção guiada por eco-Doppler. Foi utilizada anestesia por infiltração intumescente perivasal com solução de lidocaína a 0,2 por cento (50-150 ml). A potência e duração do pulso foram determinadas pelo diâmetro da veia. Os controles foram realizados com eco-Doppler aos 7 dias, 1 mês, 3 meses, 6 meses, 1 ano e, a seguir, anualmente, para avaliar a eficácia do tratamento e os efeitos adversos. RESULTADOS: A oclusão primária da veia safena magna foi obtida em 405 dos 417 membros (97,1 por cento) tratados. Houve reintervenção em 12 casos (2,9 por cento), com sucesso. O tempo médio de observação foi de 18 meses, e, nesse período, a taxa de recidiva global de varizes foi de 7,4 por cento, sendo 6,3 por cento (26 membros) veias colaterais tributárias da crossa e 1,2 por cento (cinco membros) com recanalização da safena magna. Todas as recorrências ocorreram entre o terceiro e o 12° mês. Os efeitos indesejáveis mais freqüentes foram: equimoses (60,6 por cento); dor suportável durante o procedimento (16,1 por cento); hematomas (5,5 por cento); flebite em colaterais não-tratadas (3,4 por cento); hiperpigmentação (2,9 por cento); e parestesia transitória (3,4 por cento). Nenhum caso de tromboflebite da safena magna foi observado. Não houve nenhum caso de trombose venosa profunda ou embolia pulmonar. CONCLUSÃO: O tratamento endovenoso de varizes com laser, conforme descrito, foi eficaz para ocluir a safena magna e seus principais ramos, com efeitos adversos autolimitados e com recorrência inferior a 8 por cento no período de seguimento.

OBJETIVE: To evaluate results of endovenous laser treatment for primary varicose veins. PATIENTS AND METHOD: From July 2001 to September 2004 (39 months), 253 outpatients (417 limbs) were treated with 810 and 980 nm diode laser energy delivered percutaneously using optical fiber introduced by puncture under ultrasound guidance. Tumescent anesthesia (50-150 ml of 0.2 percent lidocaine) was delivered perivenously. Power and duration of the pulse were determined by vein diameter. Duplex control was performed at 7 days, 1 month, 3 months, 6 months, 1 year and yearly thereafter to assess treatment efficacy and adverse effects. RESULTS: Primary great saphenous vein occlusion was obtained in 405 of 417 members (97.1 percent). Twelve recurrent cases (2.9 percent) were successfully treated. Mean follow-up time was 18 months. During this period, global recurrence rate of varicose veins was 7.4 percent; 6.3 percent (26 limbs) related to tributary and collateral veins of the saphenofemoral junction, and 1.2 percent (five limbs) with great saphenous vein recanalization. All recurrences occurred between 3 and 12 months. Ecchymosis was the most common adverse effect (60.6 percent). Other complications were: moderate pain during the procedure (16.1 percent); hematoma (5.5 percent), superficial phlebitis of varicose tributaries (3.4 percent), hyperpigmentation (2.9 percent), transient paresthesia (3.4 percent). There were no cases of great saphenous vein thrombophlebitis, deep vein thrombosis or pulmonary emboli. CONCLUSION: Varicose vein treatment with endovenous laser technique was successful in occluding great saphenous vein and its branches, with self-limited adverse effects and recurrence rate lower than 8 percent in the follow-up period.